Access device

ABSTRACT

A surgical access device includes a base having two or more ports or apertures that provide for the insertion of surgical instruments. The multi-port insert may be used with a laparoscopic access device. The multi-port insert may also include one or more instrument supports that are attached to the base to fix the position of one or more surgical instruments inserted through the multi-port insert.

REFERENCE TO RELATED APPLICATIONS

The present application is a divisional of and claims priority to U.S.patent application Ser. No. 11/398,985 filed Apr. 5, 2006 (published asUS 2006/0247673 on Nov. 2, 2006), which application claims priority toU.S. provisional patent application Ser. Nos. 60/669,514, filed on Apr.8, 2005, and 60/700,176, filed on Jul. 18, 2005; all of which areincorporated herein by reference.

This application cross references and incorporates by reference thefollowing copending commonly assigned patent applications:

Multi-Port Laparoscopic Access Device, U.S. Ser. No. 11/398,985, filedApr. 5, 2006;

SURGICAL ACCESS DEVICE, U.S. Ser. No. 11/399,172, filed Apr. 5, 2006;

TISSUE MARKER AND METHOD FOR USE, U.S. Ser. No. 11/399,045, filed Apr.5, 2006;

INTRA-ABDOMINAL STORAGE DEVICE, U.S. Ser. No. 11/399,044, filed Apr. 5,2006;

TISSUE RETRACTION DEVICE, U.S. Ser. No. 11/399,149, filed Apr. 5, 2006;

SURGICAL INSTRUMENT SYSTEM, U.S. Ser. No. 11/399,145, filed Apr. 5,2006; and

TISSUE SUSPENSION DEVICE, U.S. Ser. No. 11/399,181, filed Apr. 5, 2006.

FIELD OF THE INVENTION

The present application relates to methods and devices for surgicalprocedures and, more particularly, to laparoscopic procedures.

BACKGROUND

In a minimally invasive, laparoscopic surgical procedure, a surgeon mayplace a number of small ports into the abdomen to gain access into theabdominal cavity of the patient. A surgeon may use, for example, a portfor insufflating the abdominal cavity to create space, a port forintroducing a laparoscope for viewing, and a number of other ports forintroducing surgical instruments for operating on tissue. The benefitsof minimally invasive procedures compared to open surgery procedures fortreating certain types of wounds and diseases are now well-known toinclude faster recovery time and less pain for the patient, betteroutcomes, and lower overall costs.

In traditional, open surgery, surgeons may use their hands, togetherwith surgical instrumentation, to manipulate tissues, to performparticular steps of the procedure and to obtain tactile feedback throughtheir fingertips to verify the nature of particular tissues. Also inopen surgery, the size and shape of instruments that a surgeon may placeinto the abdominal cavity, as well as the size and shape of tissues thata surgeon may remove, obviously is not nearly as limited as inlaparoscopic surgery.

Hand-assisted, laparoscopic surgery (“HALS”) combines some of thebenefits of both the open and the laparoscopic methods. In a HALSprocedure, a surgeon still places small ports into the abdomen toinsufflate, to view and to introduce instruments into the abdominalcavity. In a HALS procedure, however, a surgeon also creates an incisioninto the abdominal wall large enough to accommodate the surgeon's hand.The incision may be retracted and draped to provide a suitably sized andprotected opening. A surgeon may also place a laparoscopic accessdevice, also referred to as a lap disc, into the incision to maintaininsufflation in the abdominal cavity while the surgeon's hand is eitherinserted into the cavity though the device or removed from the cavity.The advent of HALS and the lap disc creates numerous opportunities forcreating and/or improving surgical devices and methods.

SUMMARY

A surgical access device is provided for surgical access through anincision in the body wall to the inside of a body cavity of a patient. Amulti-port insert is provided for use with a laparoscopic access device.The multi-port insert includes a base having two or more ports orapertures that provide for the insertion of surgical instruments. Themulti-port insert 100 may be used with a laparoscopic access device,such as a Lap Disc Hand Access Device model #LD111, commerciallyavailable from Ethicon Endo-Surgery, Inc. of Cincinnati, Ohio. Themulti-port insert provides for the insertion of one or more surgicalinstruments through the laparoscopic access device. Each port oraperture in the base includes its own seal assembly to provide a sealand prevent the escape of insufflation gases.

In one embodiment the multi-port insert may also include one or moreinstrument supports that are attached to the base to fix the position ofone or more surgical instruments inserted through the multi-port insert.

A method is also provided for accessing a body cavity of a patientduring a surgical procedure. The method includes providing an accessdevice that includes a subassembly having a multi-port insert. Theaccess device is positionable in the incision and defines a passagewaythrough the body wall between the opening in the subassembly and thebody cavity. The surgical access device further includes at least twoaccess channels for insertion of one or more surgical instrumentsthrough the access device. The method further includes providing atleast one instrument support on the access device for supporting one ormore surgical instruments inserted through the multi-port insert.

BRIEF DESCRIPTION OF THE DRAWINGS

The novel features of the invention are set forth with particularity inthe appended claims. The invention itself, however, both as toorganization and methods of operation, may best be understood byreference to the following description, taken in conjunction with theaccompanying drawings in which:

FIG. 1-1 is a perspective view of a first aspect of a base;

FIG. 1-2 is a top view of the base of FIG. 1-1;

FIG. 1-3 is a sectional side view of a first aspect of a seal assemblyfor use with the base of FIG. 1-1;

FIG. 1-4 is a top view of the seal assembly of FIG. 1-3;

FIG. 1-5 is a sectional side view of a first embodiment of the base ofFIG. 1-1;

FIG. 1-6 is a sectional side view of an alternate embodiment of the baseof FIG. 1-5;

FIG. 1-7 is a sectional side view of a laparoscopic access deviceincluding the base of FIG. 1-5;

FIG. 1-8 is an expanded cross-sectional view of an instrument support;

FIG. 1-9 is a view of the instrument support of FIG. 1-8 in an assembledstate;

FIG. 1-10 is a sectional view of an alternate embodiment of aninstrument support;

FIG. 1-11 is a sectional view of a third embodiment of an instrumentsupport;

FIG. 1-12 is a sectional view of a fourth embodiment of an instrumentsupport;

FIG. 2-1 is a partially sectioned front view of an access device of theprior art;

FIG. 2-2 is a partially sectioned front view of a first aspect of anaccess device;

FIG. 2-3 is a top view of the access device shown in FIG. 2-2;

FIG. 2-4 is a sectional view of a port of the access device shown inFIG. 2-3;

FIG. 2-5 is a partially sectioned front view of a second aspect of anaccess device;

FIG. 2-6 is a top view of the access device shown in FIG. 2-5;

FIG. 2-7 is schematic representation of a third aspect of an accessdevice;

FIG. 2-8 is a partial side view of a fourth aspect of an access device;

FIG. 2-9 is a partial top view, taken at line 9-9 of FIG. 2-10, of theaccess device shown in FIG. 2-8;

FIG. 2-10 is a partial front, sectional view taken at line 10-10 of FIG.2-9, of the access device shown in FIG. 2-8;

FIG. 3-1 is a top view of a first aspect of a tissue marker;

FIG. 3-2 is a side view of the tissue marker shown in FIG. 3-1, while ina flat configuration;

FIG. 3-3 is a side view of the tissue marker shown in FIG. 3-1, while ina deployed configuration;

FIG. 3-4 is a sectional view of the tissue marker shown in FIG. 3-1being attached to tissue;

FIG. 3-5A is a perspective view of two tissue markers of FIG. 3-1, eachincluding a flag and attached to tissue;

FIG. 3-5B is a perspective view of the tissue marker shown in FIG. 3-1,but with an alternate embodiment of a flag, shown in a non-extendedposition;

FIG. 3-5C is a perspective view of the tissue marker shown in FIG. 3-5B,with the flag shown in an extended position;

FIG. 3-6 is a top view of a second aspect of a tissue marker;

FIG. 3-7 is a side view of the tissue marker shown in FIG. 3-6, shownbefore deployment;

FIG. 3-8 is a side sectional view of the tissue marker shown in FIG.3-6, shown after deployment;

FIG. 3-9 is a top view of a third aspect of a tissue marker;

FIG. 3-10 is a side sectional view of the tissue marker shown in FIG.3-9; shown before deployment;

FIG. 3-11 is a side view of the tissue marker shown in FIG. 3-9, shownafter deployment;

FIG. 3-12 is a top view of a fourth aspect of a tissue marker;

FIG. 3-13 is a side sectional view of the tissue marker shown in FIG.3-12, shown before deployment;

FIG. 3-14 is a side view of the tissue marker shown in FIG. 3-12, shownafter deployment;

FIG. 3-15 is a side view of a fifth aspect of a tissue marker;

FIG. 3-16 is an end view of the tissue marker shown in FIG. 3-15;

FIG. 3-17 is a front view of the tissue marker shown in FIG. 3-15, shownbefore deployment;

FIG. 3-18 is a front view of the tissue marker shown in FIG. 3-15, shownafter deployment;

FIG. 3-19 is an end view of a sixth aspect of a tissue marker;

FIG. 3-20 is a front view of the tissue marker shown in FIG. 3-19, shownbefore deployment;

FIG. 3-21 is a front view of the tissue marker shown in FIG. 3-19, shownafter deployment;

FIG. 3-22 is a top view of a seventh aspect of a tissue marker;

FIG. 3-23 is a front view of the tissue marker shown in FIG. 3-22, shownbefore deployment;

FIG. 3-24 is a front view of the tissue marker shown in FIG. 3-22, shownafter deployment;

FIG. 3-25 is a top view of an eighth aspect of a tissue marker;

FIG. 3-26 is a side view of the tissue marker shown in FIG. 3-25;

FIG. 3-27 is a top view of a ninth aspect of a tissue marker;

FIG. 3-28 is a side view of the tissue marker shown in FIG. 3-27, shownbefore deployment;

FIG. 3-29 is a side view of the tissue marker shown in FIG. 3-27, shownafter deployment;

FIG. 3-30 is a top view of a tenth aspect of a tissue marker;

FIG. 3-31 is a side view of the tissue marker shown in FIG. 3-30, shownbefore deployment;

FIG. 3-32 is a side view of the tissue marker shown in FIG. 3-30, shownafter deployment;

FIG. 3-33 is a side view of a first embodiment of a marking fluidapplier;

FIG. 3-34 is a partial side view of a second embodiment of a markingfluid applier;

FIG. 3-35 is a partial top view of the marking fluid applier shown inFIG. 3-34;

FIG. 3-36 is an enlarged view of a tissue interfacing surface of themarking fluid applier shown in FIG. 3-34;

FIG. 3-37 is an illustration of a plurality of tissue markings on thecolon of a surgical patient;

FIG. 3-38 is an illustration of a tissue marker being deployed ontotissue with a surgical instrument;

FIG. 3-39 is an illustration of a marking fluid being applied to tissue;

FIG. 3-40 is an illustration of a colon of a surgical patient prior toresection;

FIG. 3-41 is an illustration of a colon of a surgical patient duringresection;

FIG. 3-42 is an illustration of a colon of a surgical patient afterresection;

FIG. 4-1 is a perspective view of a first aspect of a storage device;

FIG. 4-2 is a perspective view of a second aspect of a storage device;

FIG. 4-3 is a perspective view of a third aspect of a storage device;

FIG. 4-4 is a perspective view of a fourth aspect of a storage device;

FIG. 4-5 is a perspective view of a storage device, including a firstembodiment of an attaching element;

FIG. 4-6 is a perspective view of a storage device, including a secondembodiment of an attaching element;

FIG. 4-7 is a perspective view of a storage device, including a thirdembodiment of an attaching element;

FIG. 4-8 is a perspective view of a storage device, including a fourthembodiment of an attaching element;

FIG. 4-9 illustrates a storage device positioned against the inside ofthe body wall of the patient;

FIG. 4-10 illustrates a storage device removably attached to a trocarcannula, which is positioned through the body wall of the patient;

FIG. 4-11 illustrates a storage device in a closed configuration andremovably attached to the trocar cannula, which is positioned throughthe body wall of the patient;

FIG. 4-12 illustrates a storage device in an open configuration andpositioned inside the body cavity, and prior to the removable attachmentof a cap onto an attaching rod;

FIG. 4-13 illustrates a storage device in a closed configuration andpositioned inside the body cavity, and after the removable attachment ofthe cap onto the attaching rod;

FIG. 5-1 illustrates a first aspect of a surgical retraction deviceretracting the colon of a surgical patient;

FIG. 5-2 is a perspective view of a second aspect of a retractiondevice;

FIG. 5-3 is a perspective view of a third aspect of a retraction device;

FIG. 5-4 is a perspective view of a fourth aspect of a retractiondevice, while in a closed configuration;

FIG. 5-5 is a perspective view of the retraction device shown in FIG.5-4, while in an opened configuration;

FIG. 5-6 is a perspective view of a fifth aspect of a retraction device;while in a closed configuration;

FIG. 5-7 is a perspective view of the retraction device shown in FIG.5-6, while in an opened configuration;

FIG. 5-8 is a perspective view of a sixth aspect of a retraction device;

FIG. 5-9 is a perspective view of an seventh aspect of a retractiondevice;

FIG. 5-10 illustrates an eighth aspect of a retraction device retractingthe colon of a surgical patient;

FIG. 5-11 illustrates a ninth aspect of a retraction device retractingthe colon of a surgical patient;

FIG. 5-12 is a perspective view a tenth aspect of a retraction device ina closed configuration;

FIG. 5-13A is a perspective view the retraction device shown in FIG.5-12, while in a partially open configuration;

FIG. 5-13B is a perspective view the retraction device shown in FIG.5-12, while in an open configuration;

FIG. 5-14 is a perspective view of an eleventh aspect of a retractiondevice;

FIG. 5-15 is a perspective view of a twelfth aspect of a retractiondevice;

FIG. 5-16 is a side view of a thirteenth aspect of a retraction devicewhile in an opened configuration;

FIG. 5-17 is a side view of the retraction device shown in FIG. 5-16,while in a partially opened configuration;

FIG. 5-18 is a side view of the retraction device shown in FIG. 5-1,6while in a closed configuration;

FIG. 5-19 illustrates a fourteenth aspect of a retraction deviceretracting the colon of a surgical patient;

FIG. 5-20 is a perspective view of an arm of the retraction device shownin FIG. 5-19;

FIG. 5-21 is a sectional view of a fifteenth aspect of a retractiondevice, while in a closed configuration and being passed through alaparoscopic port;

FIG. 5-22 is an end view of the retraction device shown in FIG. 5-21,while in the closed configuration;

FIG. 5-23 is a front view of the retraction device shown in FIG. 5-21,while in the closed configuration;

FIG. 5-24 is a front view of a sixteenth aspect of a retraction device;

FIG. 5-25 illustrates an seventeenth aspect of a retraction deviceretracting the colon of a surgical patient;

FIG. 5-26A is a front view of the retraction device shown in FIG. 5-25,while in an open configuration;

FIG. 5-26B is a front view of the retraction device shown in FIG. 5-25,while in a partially closed configuration;

FIG. 5-27 illustrates an eighteenth aspect of a retraction deviceretracting the colon of a surgical patient;

FIG. 5-28 illustrates a nineteenth aspect of a retraction deviceretracting the colon of a surgical patient;

FIG. 5-29 is a perspective view of a twentieth aspect of a retractiondevice;

FIG. 5-30 is a front view of a twenty-first aspect of a retractiondevice, while in a first, partially closed configuration;

FIG. 5-31 is a front view of the retraction device shown in FIG. 5-30,while in a second, partially closed configuration;

FIG. 5-32 is a front view of the retraction device shown in FIG. 5-30,while in an opened configuration;

FIG. 5-33 is a top view of a twenty-second aspect of a retractiondevice;

FIG. 5-34 is a front view of the retraction device shown in FIG. 5-33;

FIG. 5-35 is a top view of a twenty-third aspect of a retraction device;

FIG. 5-36 is a front view of the retraction device shown in FIG. 5-35;

FIG. 5-37A is a top view of a twenty-fourth aspect of a retractiondevice;

FIG. 5-37B is a detailed, top view of the retraction device shown inFIG. 5-37A, while being rolled up into a closed configuration;

FIG. 5-38 is a front view of the retraction device shown in FIG. 5-37;

FIG. 5-39 is a top view of a twenty-fifth aspect of a retraction device;

FIG. 5-40 is a front view of the retraction device shown in FIG. 5-39;

FIG. 5-41 is an end view of the retraction device shown in FIG. 5-39;

FIG. 5-42 is a front view of a twenty-sixth aspect of a retractiondevice;

FIG. 5-43 is a front view of the retraction device shown in FIG. 5-42,while in a twisted configuration;

FIG. 5-44 is a top view of a twenty-seventh aspect of a retractiondevice;

FIG. 5-45 is a front view of the retraction device shown in FIG. 5-44;

FIG. 5-46 is a top view of a twenty-eighth aspect of a retractiondevice;

FIG. 5-47 is a front view of the retraction device shown in FIG. 5-46;

FIG. 5-48 is a top view of a twenty-ninth aspect of a retraction device;

FIG. 5-49 is a front view of the retraction device shown in FIG. 5-48;

FIG. 5-50 is a top view of a thirtieth aspect of a retraction device;

FIG. 5-51 is a front view of the retraction device shown in FIG. 5-50,while in a closed configuration;

FIG. 5-52 is a front view of the retraction device shown in FIG. 5-50,while in an opened configuration;

FIG. 5-53 is a front view of a thirty-first aspect of a retractiondevice;

FIG. 5-54 is a top view of the retraction device shown in FIG. 5-53,when opened;

FIG. 5-55 is a top view of the retraction device shown in FIG. 5-53,when folded;

FIG. 5-56 is a front view of a thirty-second aspect of a retractiondevice;

FIG. 5-57 is an end view of the retraction device shown in FIG. 5-56;

FIG. 6-1 is a front view of the distal portion of a surgical instrument,shown with a first aspect of an end effector;

FIG. 6-2 is a sectional view, taken at line 2-2 of FIG. 1, of a firstembodiment of an arm of the surgical instrument;

FIG. 6-3 is a front sectional view of the first embodiment of the arm ofthe surgical instrument shown in FIG. 6-1;

FIG. 6-4 is a front sectional view of a second embodiment of an arm of asurgical instrument;

FIG. 6-5 is an end view of a second aspect of an end effector;

FIG. 6-6 is a front view of the end effector shown in FIG. 6-5;

FIG. 6-7 is an end view of a third aspect of an end effector;

FIG. 6-8 is a front view of the end effector shown in FIG. 6-7;

FIG. 6-9 is a front view of the distal portion of a surgical instrument,shown with a fourth aspect of an end effector;

FIG. 6-10 is a top view of the end effector shown in FIG. 6-9;

FIG. 6-11 is an end view of the end effector shown in FIG. 6-9;

FIG. 6-12 illustrates part of a first method for performing ahand-assisted, laparoscopic procedure;

FIG. 6-13 illustrates part of a second method for performing ahand-assisted, laparoscopic procedure;

FIG. 7-1 is a side view of a patient;

FIG. 7-2 is a cross-sectional view of a patient's abdomen, taken at line2-2 of FIG. 7-1;

FIG. 7-3 is an end view of a first aspect of a tissue suspension device;

FIG. 7-4 is a side view of the tissue suspension device shown in FIG.7-3;

FIG. 7-5 is an enlarged side view of a second end of the tissuesuspension device shown in FIG. 7-3;

FIG. 7-6A is an enlarged side view of a first end of the tissuesuspension device shown in FIG. 7-3;

FIG. 7-6B is an isometric view of the first end of the tissue suspensiondevice shown in FIG. 7-3, assembled to a supporting element;

FIG. 7-7 is an end view of a second aspect of a tissue suspensiondevice;

FIG. 7-8 is a side view of the tissue suspension device shown in FIG.7-7;

FIG. 7-9 is an enlarged view of a support element on the end of thetissue suspension device shown in FIG. 7-7;

FIG. 7-10 is top view of a retaining element of the support elementshown in FIG. 7-9;

FIG. 7-11 is a partial side view of a third aspect of a tissuesuspension device;

FIG. 7-12 is a partial side view of a fourth aspect of a tissuesuspension device; and

FIG. 7-13 is a partial side view of a fifth aspect of a tissuesuspension device.

DETAILED DESCRIPTION

Before explaining the present invention in detail, it should be notedthat the invention is not limited in its application or use to thedetails of construction and arrangement of parts illustrated in theaccompanying drawings and description. The illustrative embodiments ofthe invention may be implemented or incorporated in other embodiments,variations and modifications, and may be practiced or carried out invarious ways. Further, unless otherwise indicated, the terms andexpressions employed herein have been chosen for the purpose ofdescribing the illustrative embodiments of the present invention for theconvenience of the reader and are not for the purpose of limiting theinvention.

Further, it is understood that any one or more of thefollowing-described embodiments, expressions of embodiments, examples,etc. can be combined with any one or more of the otherfollowing-described embodiments, expressions of embodiments, examples,etc.

Multi-Port Insert

A first aspect of a multi-port insert, generally designated 100, relatesto an insert for use with a laparoscopic access device 122. Referringnow to the figures, FIG. 1-1 and FIG. 1-2 depict one embodiment of themulti-port insert 100. The multi-port insert 100 includes a base 102having two or more ports or apertures 104 that provide for the insertionof surgical instruments. The multi-port insert 100 may be used with alaparoscopic access device 122 (FIG. 1-7) such as a Lap Disc Hand AccessDevice model #LD111, commercially available from Ethicon Endo-Surgery,Inc. of Cincinnati, Ohio. The multi-port insert provides for theinsertion of one or more surgical instruments through the laparoscopicaccess device 122, while preventing insufflation gases from escapingfrom the body cavity.

As illustrated in FIG. 1-1 and FIG. 1-2, the base 102 may include fourseparate apertures 104 spaced evenly around the center of the base 102with each aperture 104 having a raised lip or rim 106. Thisconfiguration allows surgical tools, such as gripping devices to beinserted through two apertures 104. The gripping devices may be used tomanipulate or lift a portion of the bowel to provide the surgeon withaccess to the either the bowel tissue being manipulated or theunderlying tissue. An endoscope including a camera and light may beinserted through a third aperture 104 to provide the surgeon with theability to view the interior of the body cavity. An additional surgicalinstrument, such as a needle, scissors, an ultrasonic transducer or anyother surgical instrument, may be inserted through the fourth aperture104. Although FIG. 1-1 and FIG. 1-2 illustrate a base 102 including fourapertures 104, alternate numbers and configurations of apertures may beused. In addition, a base 102 may include apertures 104 of varying sizesable to provide for the insertion of differently sized surgicalinstruments. In one embodiment the apertures may be sized to provide forinstruments between five and twelve millimeters in diameter. The base102 may also include an reference indicator 180 that may be used by thesurgeon as a reference point during laparoscopic procedures.

Referring now to FIG. 1-3 and FIG. 1-4, each port or aperture 104 in thebase 102 includes its own seal assembly 108 to provide a seal andprevent the escape of insufflation gases. There are many possible typesof seals which may be utilized in the seal assembly 108. In oneembodiment, each seal assembly 108 includes an iris seal 110 and a duckbill valve 112 such as the seal assembly described in U.S. PatentApplication Publication No. 2004/0230161 (Ser. No. 10/815,356; filedMar. 31, 2004) to Zeiner, the entire contents of which are herebyincorporated herein by reference. Each iris seal 110 may include aplurality of layered elastic members 114 having a semi-circular profiledisposed between two rigid seal rings 116. The elastic members 114 mayform a conical-shaped seal such that when a surgical instrument isinserted from the top side thereof, the elastic members 114 aredisplaced downwardly and radially outwardly and form a seal around thesurgical instrument. Each seal assembly 108 may also include azero-closure valve such as a duckbill valve 112 to prevent the sealassembly 108 from leaking when there is no surgical instrument insertedthrough the seal assembly 108. The duckbill valve 112 may include twooverlapping flaps 113. Pressure from below the duckbill valve 112 pushesthe flaps 113 together, maintaining the seal. Pressure from above theduckbill valve 112 pushes the flaps 113 apart, allowing a surgicalinstrument to pass through.

In one embodiment, each seal assembly 108 is flexibly attached to thebase 102 using a floatation system such as bellows 118 located aroundthe periphery of each seal assembly 108. The bellows 118 may be madefrom a flexible, elastic material and allow the seal assembly 108 tomove laterally and pivot within the aperture 104. The movement of theseal assembly 108 allows surgical instruments to be inserted through theapertures 104 at an angle rather than along the axis of the aperture104. The bellows 118 may be attached to the lip of the aperture 104 by aretaining ring 120 that frictionally fits over each rim 106. The forcerequired to deflect the bellows 118 is much less than the pressureexerted by surgical instrument on the elastic members 114 while thesurgical instrument is inserted in the seal assembly 108. This allowsthe floatation system to deflect within each aperture 104 while theelastic members 114 maintain a sealing condition with the instrument.

The multi-port insert 100 may be attached to a laparoscopic accessdevice 122 as shown in FIG. 1-7. The laparoscopic access device 122 mayinclude a generally coaxially aligned upper ring 146 and lower ring 148and a membrane 128 coupled to and extending generally axially betweenthe upper ring 146 and lower ring 148. The membrane 128 has a centralopening of variable size. For example, in one embodiment the upper ring146 and lower ring 148 are rotatable in opposite directions relative toone another to change the size of the opening. The base 102 of themulti-port insert 100 may be attached to the laparoscopic access device122 by a simple latch mechanism 124 to allow the multi-port insert 100to be attached to currently available laparoscopic access devices 122.Alternatively, one or more C-clamps or other clamping devices orstructures may be used to attach the multi-port insert 100 to alaparoscopic access device 122. In addition, the multi-port insert 100may be attached to a laparoscopic access device 122 using a threadablesurface on the multi-port insert 100 and a corresponding matingthreadable surface on the laparoscopic access device 122.

Once attached to the laparoscopic device, the base 102 of the multi-portinsert 100 may form a seal with the laparoscopic access device 122 toprevent the escape of insufflation gas. As shown in FIG. 1-5, the base102 may include a collar 126 that may be inserted into the laparoscopicaccess device 122. As illustrated in FIG. 1-7, the collar 126 extendsinto the laparoscopic access device 122 and forms a seal with themembrane. In addition, the collar 126 may also protect the membrane 128of the laparoscopic access device from any surgical instruments insertedthrough the apertures 104. As depicted in FIG. 1-5, the collar 126 mayinclude a generally tapered portion 127. The tapered portion 127 allowsthe apertures 104 to be seated within the laparoscopic access device122. Lowering the apertures 104 lowers the pivot points of the surgicalinstruments and increases the range of motion of the surgicalinstruments inserted through the apertures 104. In an alternateembodiment, the collar 126 does not include a tapered portion and may begenerally cylindrically shaped.

In an alternate embodiment illustrated in FIG. 1-6, a resilient layer150 may be located on a lower surface of the base 102 such that when themulti-port insert 100 is attached to the laparoscopic access device 122,the resilient layer 150 forms a seal between the multi-port insert 100and the laparoscopic device. The resilient layer 150 may be formed froma closed-cell elastomer or any other suitable material.

In another embodiment, the base 102 of the multi-port insert may beinserted through the opening in the membrane 128 of the laparoscopicaccess device 122 and attached to the lower ring 148 of the laparoscopicaccess device 122. This configuration would provide a greater range ofmotion within the body cavity for the surgical instruments by loweringthe pivot points for the instruments below the surface of the skin.

The multi-port insert 100 may also include one or more instrumentsupports 130 that are attached to the base 102 to fix the position ofone or more surgical instruments inserted through the multi-port insert100. FIG. 1-8 illustrates a first embodiment of a surgical instrumentsupport 130 extending generally axially from the base 102. The surgicalinstrument support 130 may include a gripping portion 138, a stem 154and an instrument support base 134. The gripping portion 138 may be usedto hold one or more surgical instruments and may include a C-clamp orany other device suitable for holding a surgical instrument. The stem154 connects the gripping portion 138 and the instrument support base134. In one embodiment, the stem 154 may be composed of a malleablesubstance, such as copper wire, to allow the surgical instrument support130 to be positioned to hold a surgical instrument.

The instrument support base 134 attaches the instrument support 130 tothe multi-port insert 100. The base 134 may be inserted into a track 132that extends around the periphery of the multi-port insert 100. Thetrack 132 may include an opening 178 to allow an instrument support base134 to be inserted into the track 132. The instrument support 130 may bepositioned along the track 132 around the circumference of themulti-port insert 100.

The instrument support 130 includes a positional lock 136 for fixing theposition of the instrument support base 134 with respect to themulti-port insert 100. The stem 154 may be inserted through an aperturein the positional lock 136. The positional lock 136 may be threadablyconnected to the instrument support base 134, such that when thepositional lock 136 is rotated in a first direction the instrumentsupport base 134 is drawn upward away from the base 102. Frictionalforces between the track 132, the instrument support base 134 and thepositional lock 136 secure the instrument support base 134 relative tothe base 102 of the multi-port insert 100. In an alternative embodiment,a clamp may be used to secure the instrument support 130 to the base102.

The instrument support 130 may also include an extension control 152 andan extension lock 140. The extension control 152 includes a generallyconical portion 166 and an aperture shaped to receive the stem 154. Theconical portion 166 of the extension control 152 includes one or moreslits (not shown). The extension lock 140 includes an aperture shaped toreceive the stem 154 and a generally conical shaped opening 156. Theextension lock 140 may be threadably connected to the extension control152 such that the extension lock 140 may be drawn downward over theextension control 152. The pressure exerted by the extension lock 140 onthe extension control 152 pushes the conical portion 166 of theextension control 152 down and inward, exerting pressure against thestem 154, preventing the stem 154 from sliding through the apertures inthe extension control 152 and thereby locking the stem 154 in place. Thesurface of the stem 154 may be rough, textured or covered with a coatingto increase friction between the stem and the extension control 152 andfacilitate locking the stem 154 in place.

FIG. 1-10 illustrates an alternate embodiment of an instrument support130′ in which the instrument support 130′ covers and is radially alignedwith an aperture 104 of the multi-port insert 100. The instrumentsupport 130′ may be attached to one or more of the apertures 104. One ormore of the rims 106 may be shaped to form a socket-shaped housing 142′.The instrument support 130′ includes an instrument support base 134′having a semispherical portion seated within the housing 142′. Theinstrument support base 134′ is capable of pivoting within the housing142′ to provide a range of motion to the surgical instruments receivedtherethrough. The instrument support 130′ may include a rotation lock164′ threadably connected to the instrument support base 134′. Rotatingthe rotation lock 164′ in a first direction causes the rotation lock164′ to exert pressure downward on the housing 142′ while at the sametime drawing the instrument support base 134′ upward against the housing142′. The frictional forces between the instrument support base 134′,the housing 142′ and the rotational lock 164′ may prevent the instrumentsupport base 134′ from pivoting or rotating within the housing 142′.

The instrument support 130′ may include an instrument contact ring 160′and an instrument locknut 162′ designed to control the depth ofinsertion into the body cavity of the surgical instruments. Theinstrument locknut 162′ may be threadably connected to the instrumentsupport base 134′ such that, when the locknut 162′ is rotated andengages the threads of the instrument support base 134′, the locknut162′ exerts pressure against the instrument contact ring 160′ causingthe contact ring 160′ to close around the surgical instrument andthereby controlling the depth of insertion of the instrument.

FIG. 1-11 illustrates a third embodiment of an instrument support 130″.This embodiment also covers and is radially aligned with an aperture 104of the multi-port insert 100. The instrument support 130″ may include asocket-shaped, metalized or metal impregnated housing 142″ that attachesto the upper surface of the base. The instrument support 130″ includesan instrument support base 134″ having a semispherical portion whichrests upon the housing 142″. The instrument support base 134″ is capableof pivoting on the housing 142″ to provide a range of motion to thesurgical instruments received therethrough. The instrument support 130″may include includes one or more magnets 170″ attached to the instrumentsupport base 134″. The attraction between the housing 142″ and themagnets 170″ holds the instrument support base 134″ in place relative tothe housing 142″. The instrument support 130″ includes an elastic boot168″ attached to the housing 142″ and the instrument support base 134″.The elastic boot 168″ maintains a seal and prevents the escape ofinsufflation gases. As in the previous embodiment, the instrumentsupport 130″ may include seal assembly 108, an instrument contact ring160 and an instrument lopg. 23cknut 162 to control the depth ofinsertion of a surgical instrument. The seal assembly 108 may include aduckbill valve 112 and an iris seal 110.

FIG. 1-12 illustrates a further embodiment of the instrument support130′″ in which the housing 142′″ may include a set of concentric ridges172′″. The instrument support base 134′″ may include one or more legs174′″ include a set of teeth 176′″ that mate with the ridges 172′″ ofthe housing 142′″ to hold the instrument support base 134′″ in placerelative to the housing 142′″. In this embodiment, the elastic boot168′″ attaches holds the instrument support base 134′″ in contact withthe housing 142′″.

The multi-port insert may be utilized during laparoscopic procedures toprovide the surgeon with the ability to insert multiple surgicalinstruments into the body cavity of the patient without substantial lossof insufflation gases and without requiring multiple additionalincisions. In one embodiment the lower ring of the laparoscopic accessdevice 122 may be inserted into the body of a patient through anincision in the abdomen of the patient. During laparoscopic surgery, thesurgeon may elect to attach a multi-port insert 100 to the upper ring148 of the laparoscopic access device 122 using the latch mechanisms124, clamps or the like. Once attached, the multi-port insert 100 formsa seal with the laparoscopic access device 122. The seal between themulti-port insert 100 and the laparoscopic access device 122 and theseal assemblies 108 prevent excessive amounts of the insufflation gasesfrom escaping the body cavity. The surgeon may insert a surgicalinstrument through any or all of the apertures 104. This allows thesurgeon to insert multiple surgical instruments into the body cavitypatient at the same time. The seal assemblies 108 automatically resealupon removal of the surgical instruments allowing the surgeon to insertand remove multiple surgical instruments during surgery.

The multi-port insert 100 may also include one or more instrumentsupports 130 designed to hold surgical instruments inserted through themulti-port insert. In one embodiment the instrument supports 130 attachto the track 132 in the base 102. The instrument supports 130 may bepositioned at an appropriate location on the base 102 and locked intoplace using the positional lock 136. The surgeon may control thedistance the instrument support 130 extends from the base 102 using theextension control 152 and extension lock 140. The instrument support 130may be attached to a surgical instrument using the gripping portion 138.The surgeon may reposition and readjust the instrument support 130 atany time. At any time during the procedure the surgeon may elect todisconnect the multi-port insert 100 from the laparoscopic access device122.

Surgical Access Device

FIG. 2-1 is a partially sectioned front view of an access device 202 ofthe prior art, positioned in a body wall 299 of a patient. Access device202 is disclosed in U.S. Pat. No. 6,110,154, which issued to Shimomuraet al. on Aug. 29, 2000, and is titled “Valve and Valved Trocar JacketTube.” Access device 202 includes an upper ring 204, a lower ring 206, afirst cylindrical elastic member 208 (or first elastic member 208), asecond cylindrical elastic member 210 (also referred to as secondelastic member 210 and sleeve 210), and a resilient member 212. Firstelastic member 208 and second elastic member 210 are each made of athin-walled, silicone rubber tubing material, or any one of a number ofother elastic, biocompatible materials in sheet or tube form. The endsof first elastic member 208 are assembled with upper ring 204 and lowerring 206, respectively, to form a hyperboloid (“hour glass”) shapedefining an opening 250 centered on a vertical axis 249 of access device202. Similarly, the ends of second elastic member 210 are assembled withlower ring 206 and resilient ring 212 to form a hyperboloid shape anddefining a passageway 223 therethrough. The surgeon may position secondelastic member 210 in the body wall 299 of the patient by pushingresilient ring 212 (while folded) through the surgical incision. Once inthe body cavity, resilient ring 212 resumes an approximately circularshape to sealingly retain access device 202 in body wall 299. An annularinterface 211 between upper ring 204 and lower ring 206 frictionallyholds the relative angular orientation of upper ring 204 and lower ring206 in order to maintain the size of opening 250. The frictional holdingforce is easily overcome by the surgeon turning either one of upper ring204 and lower ring 206 while holding the other. Additionally, upper ring204 and lower ring 206 may each be molded from a plastic to haveinterlocking features around the perimeter of their mating surfaces. Thesurgeon may accordingly adjust the relative angular position aboutvertical axis 249 of upper ring 204 with respect to lower ring 206, andthus set the size of opening 250 to numerous diameters ranging from afully closed configuration to a fully open configuration. The surgeonmay adjust opening 250, therefore, to seal against the surgeon's hand orone or more surgical instruments extending through opening 250,providing the ability to insufflate the body cavity with carbon dioxideduring the surgical procedure.

Upper ring 204, lower ring 206 and first elastic member 208 are alsoreferred to together as a valve subassembly 201. As will become apparentto those skilled in the art, the aspects and features described hereinare also applicable to surgical access devices having other types ofvalve assemblies such as, for example, those including a hydrophilic gelmaterial with a sealable slit opening for surgical access into the bodycavity.

FIG. 2-2 is a front view and FIG. 2-3 is a top view, of a first aspectof an access device 222 while in a closed configuration. Access device222 includes a tubular access channel 238 extending from a lower ring226 to a resilient ring 232. The surgeon may position a second elasticmember 230 in the surgical incision and adjust an upper ring 224 withrespect to lower ring 226 to set the size of opening 250 in a firstelastic member 228 as described for access device 202 of FIG. 2-1.Access channel 238 increases the overall functionality of access device202. The surgeon may use access channel 238 to introduce ancillary,remotely operable, surgical implements and/or accessories into the bodycavity of the patient, separate from and without obstructing opening 250and passageway 223. Access channel 238 may be made of, but is notlimited to, any one of numerous flexible, biocompatible materialsincluding polyvinyl chloride, polyethylene, silicone rubber, andpolyurethane extruded tubing. A proximal end 246 of access channel 238attaches to a port 236 having a cap 242. Port 246 attaches to a tab 234extending radially from lower ring 226. Port 246, tab 234, and lowerring 226 may be injection molded unitarily. The surgeon may introduce asurgical implement into port 246 along a longitudinal axis 247, whichforms an angle 248 with longitudinal axis 249. Angle 248 may beapproximately in the range of, but is not limited to, 0-90 degrees.Access channel 238 has a distal end 244 attached to resilient member 232with a clip 240. Clip 240 may be, for example, made of a resilientmaterial, such as silicone rubber, and adhered to second elastic member230 around resilient member 232. Access channel 238 may also be adheredto the outside or inside of second elastic member 230, or moldedintegrally into the wall of second elastic member 230. Distal end 244may extend a short distance, such as 0-5 centimeters, distal toresilient member 232, and is oriented in a generally downward directionas shown. Access channel 238 has sufficient length to conform to theoutside shape of second elastic member 230 so that the body wall of thepatient may easily seal around both access channel 238 and secondelastic member 230.

Port 236 may alternately be attached to upper ring 224, rather then tolower ring 226. If port 236 is attached to upper ring 224, than accesschannel 238 would need to be long enough to wrap around second elasticelement 230, spiraling around second elastic element 230 at least onewrap, so that the surgeon may rotate upper ring 224 in either directionto adjust the size of opening 250.

FIG. 2-4 is an enlarged, sectional view of port 236 of access device 222shown in FIG. 2-2 and FIG. 2-3. Proximal end 246 of access channel 238assembles into port 236, for example, with a biocompatible adhesive.Port 236 retains a seal 237, which is made of a silicone rubber, forexample. Seal 237 has a disc shape and contains a small, central holethat may easily stretch and seal around a surgical implement and/oraccessory introduced into port 236. To maintain insufflation in the bodycavity when the surgeon is not using access channel 238, the surgeon maypress cap 242 onto port 236. Port 236 of FIG. 2-4 is shown as merely oneexample; many other versions of a sealable port assembly will becomeapparent to those skilled in the art, such as those versionsincorporating a duckbill valve, a gel, or a closed-cell foam material.The size, shape, orientation, and sealing method of port 236 may beadapted to one or more particular surgical implements and/or accessoriesto be used in the surgical procedure.

FIG. 2-5 is a front view and FIG. 2-6 is a top view, of a second aspectof an access device 252 while in an open configuration. Access device252 includes a first access channel 268 having a first port 266, asecond access channel 272 having a second port 270, a third accesschannel 276 having a third port 274, and a fourth access channel (notvisible) having a fourth port 278. Each of the ports is attached to orunitarily formed with a lower ring 256 by one of four tabs 264. Each ofthe access channels pass through one of four entrance holes 253 near theproximal end of a second elastic member 230, extend between an innerwall 259 and an outer wall 257 of second elastic member 260, and passthrough one of four exit holes 255 near the distal end of second elasticmember 230. The surgeon may position second elastic member 230 in thesurgical incision and adjust upper ring 254 with respect to lower ring256 to set the size of opening 250 in a first elastic member 258 asdescribed for access device 202 of FIG. 2-1.

FIG. 2-7 is an isometric view of a third aspect of an access device 282,shown schematically in combination with eight ancillary devices and/orsystems typically used in a surgical procedure. Access device 282 haseight access channels that are separate from and do not obstruct opening250 and passageway 223. Access device 282 includes an upper flange 283that extends from a lower ring 286. Eight inlet ports ((291, 292, 293,294, 295, 296, 297, and 298) are shown spaced apart evenly on upperflange 283 (although they may be spaced apart unevenly). Each inlet porthas a corresponding outlet port (291′, 292′, 293′, 294′, 295′, 296, 297,and 298′) attached to a flexible, lower flange attached to a secondelastic element 290. As for the second aspect of access device 252described in FIG. 2-5, each access channel is retained between inner andouter walls of second elastic element 290.

In FIG. 2-7, access device 282 is shown, by way of example, with avariety of ancillary, surgical devices and systems. Other surgicalimplements, accessories, systems, and devices will become apparent tothose skilled in the art. Some of these devices may be small enough topass through the access channel. Other devices may first need to beintroduced into the body cavity via opening 250, and then operablyconnected to the corresponding outlet port. In some instances, the inletport or outlet port may include a short pigtail connection.

In FIG. 2-7, a light source 229 operably connects to an outlet port 298′via a fiber optic bundle introduced into inlet port 298, to illuminatethe body cavity. An ultrasonic generator 227 operably connects to outletport 291′ via a cable introduced into inlet port 291. An ultrasonicdevice (not shown) may be introduced into the body cavity via opening250, and then operably connected to outlet port 291′. An electricalpower source 225 electrically connects to outlet port 292′ (hidden) viaan electrical conductor introduced into inlet port 292. Electrical powermay be used, for example, for lighting inside the body cavity, or forpowering a tissue-morcelating device (not shown). A flexible, mechanicalinstrument 231, such as a surgical grasper, is introduced into inletport 297. A drug/dye administering device 233 is shown, for directinjection into the body cavity via inlet port 293 to treat or marktissues and organs. A vacuum source 235 fluidly connects with outletport 294′ (hidden) via a tube introduced into inlet port 294, for thesuction of fluids out of the body cavity. A fluid source 241 fluidlyconnects with outlet port 296′ via a tube introduced into inlet port296, for irrigation of tissue in the body cavity. An electrosurgicalgenerator 239 electrically connects to outlet port 295′ via anelectrical conductor introduced into inlet port 295. An RF instrument(not shown) may be electrically connected to outlet port 295′ to be usedby the surgeon to cauterize tissue in the body cavity.

Each access channel described in FIG. 2-7 may include either a single ora multilumen, extruded tube. For example, a double lumen access channelmay provide both suction and irrigation functions, or electricallyisolate a pair of electrical conductors.

FIG. 2-8, FIG. 2-9, and FIG. 2-10 illustrate partial views of a fourthaspect of an access device 203, which provides the surgeon with theability to conveniently and quickly change access device 203 from aclosed or partially closed configuration to an open configuration.Access device 203 includes an intermediate ring 209 disposed between anupper ring 205 and a lower ring 207. A locking element 215 attaches toan outer circumferential surface 218 (FIG. 2-8) of upper ring 205, andreleasably locks upper ring 205 to intermediate ring 209. Intermediatering 209 has a plurality of undercut, upper teeth 213 spaced apart onthe perimeter of intermediate ring 209. Upper teeth 213 may interlockwith a like plurality of undercut, lower teeth 214 spaced apart on theperimeter of lower ring 207. When a surgeon rotates either of upper ring205 and lower ring 207 relative to the other in a first rotationaldirection, upper teeth 213 and lower teeth 214 engage to preventrelative movement of upper ring 205 and lower ring 207 in an opposite,second rotational direction, which is promoted by the spring-back forcefrom twisting first elastic member 208 as opening 250 closes. To releaseupper ring 205 from lower ring 207, the surgeon may, for example,slightly turn upper ring 205 in the first rotational direction whileholding lower ring 207, and pull upper ring 205 apart from lower ring207 to disengage the upper teeth 213 from the lower teeth 214.

Locking element 215 allows the surgeon to quickly release upper ring 205from lower ring 207, so that access device 203 may instantly spring backfrom a closed configuration to an open configuration. Locking element215 is attached at a fulcrum 219 (FIG. 2-9) on surface 218 of upper ring205. A pawl 217 of locking element 215 engages a recess 216 inintermediate ring 209 (FIG. 2-9) to lock upper ring 205 to intermediatering 209, which, in turn, locks to lower ring 207 via the engagement ofupper teeth 213 to lower teeth 214. The surgeon may press a pad 220 oflocking element 215 to unlock upper ring 205 from intermediate ring 209.The spring back force caused by the twisting of first elastic member 208while closing opening 250 allows access device 203 to immediately changeto the open configuration. When the surgeon changes access device 203from the open to the closed configuration, the relative rotation ofupper ring 205 and lower ring 207 allows pawl 217 to automaticallyengage with recess 217. Further rotation then allows upper teeth 213 andlower teeth 214 to engage in order to maintain the size of opening 250.This type of locking mechanism is incorporated into the “Lap Disc HandAccess Device,” which is available from Ethicon Endo-Surgery, Inc.,Cincinnati, Ohio.

Those skilled in the art will appreciate that numerous other aspects ofan access device are possible for providing a way to quickly changeaccess device from a closed or partially closed configuration to an openconfiguration, and that access device 203 is provided as only oneexample. Access device 203 may also incorporate at least one accesschannel as described for, but not limited to, the other aspects of theaccess device described herein.

Tissue Markers and Method for Planning a Surgical Procedure

During a surgical procedure such as hand-assisted laparoscopy, thesurgeon must identify tissue structures that are highly mobile withinthe body cavity, that have a similar coloration as surrounding tissues,and that are generally difficult to find under laparoscopicvisualization. The surgeon uses laparoscopic tools and his/her hand tomove organs and identify key, anatomical structures in order to plan thesurgical procedure. For a tissue resection, for example, in which thesurgeon cuts and removes internal tissue from the patient, the surgeongenerally needs three types of information to plan the procedure: (1)Where are the proximal and distal end points of the resection? (2) Whereis the proximal artery supplying blood to the tissue to be resected? and(3) Where should the line of resection be? Obtaining this informationmay be very time consuming, and so once the surgeon identifies a key,anatomical structure (or “landmark”), the surgeon would like to markthat area of tissue very conspicuously before searching for other keylandmarks. Then the surgeon would be able to quickly find the structureagain later during the procedure. Using the “zoom” feature on alaparoscope, and switching back and forth between a close-up view oftissue and a view of a wider area of tissue, may also disorient evenexperienced surgeons. Accordingly, a method for planning a surgicalprocedure using a tissue marker, and numerous aspects of a tissuemarker, are provided.

FIG. 3-1 through FIG. 3-32 show ten different aspects of a tissuemarker, which a surgeon may attach to tissue to indicate a key,anatomical structure. Each of the ten aspects of the tissue marker maybe applied to tissue using an applier (single or multiple deploying)that is adapted for that particular tissue marker. Other tissue markerand applier aspects or modifications are possible, and may becomeapparent to those skilled in the art.

Generally, the tissue marker aspects described herein allow fast, easy,and accurate attachment to internal, soft tissue, and are highly visiblethroughout the surgical procedure. Each tissue marker aspect alsoprovides the surgeon with the ability to label or otherwise signifymeaningful information (using color coding, written information, etc.)to the tissue, to help the surgeon to plan the surgical procedure.

Depending on the type of surgical procedure, the tissue marker may alsobe made of a material to facilitate medical imaging. For example, thetissue marker may be formed from a radio opaque material for X-rayimaging. The tissue marker may be formed from or coated with afluorescent material to enhance visibility during the procedure. Or thetissue marker may be made of a material that contains a multiplicity ofmicrobubbles for ultrasonic imaging. The tissue marker may also includea doping agent to facilitate magnetic resonance imaging.

The tissue marker may also be made of an absorbable polymer such as“Vicryl” (Ethicon, Inc., Somerville, N.J.), which may be absorbed by thepatient's body within a few weeks. Using an absorbable polymer providesthe surgeon with the option to leave the tissue marker in the body afterthe surgical procedure is completed. Of course, the tissue marker mayalso be applied to a portion of tissue that is removed from the patient.

The tissue marker may also include an antimicrobial or a drug-elutingcoating to inhibit the growth of bacteria in tissue surrounding thetissue marker.

FIG. 3-1 is a top view, FIG. 3-2 is a side view (before deployment), andFIG. 3-3 is a side view (after deployment) of a first aspect of a tissuemarker 301. FIG. 3-4 is an illustration of tissue marker 301 duringattachment to tissue, and FIG. 3-5A is an illustration of tissue marker301 after attachment to tissue. Tissue marker 301 is a thin disc ofmetal or rigid plastic, having a central, fluted aperture 302 forentrapping tissue pulled within. An applier 303 (FIG. 3-4) retainstissue marker 301 and supplies a negative pressure to pull soft tissue399 into aperture 302. Applier 303 may be attached to a length offlexible tubing that is fluidly connected to a controllable vacuumsource (not shown). Applier 303 may also include the vacuum source,which may be a hand-operable pump, for example. Tissue marker 301 mayfurther comprise a flag 304 attached to disc 301. Flag 303 may be colorcoded, preprinted with written matter (for example, “distal”), orcontain a writing area on which the surgeon may create a custom label.Flag 304 may be made of any one of a number of biocompatible materials,including a fabric, plastic, elastomer, metal foil, coiled wire, andpaper. Flag 304 may also be incorporated into the design of any of theother aspects of the tissue marker shown in FIG. 3-6 through FIG. 3-32.

FIG. 3-5B and FIG. 3-5C show a tissue marker 356 having an exemplaryembodiment of a flag 359 that is formed from a flat coil of spirallywound, malleable material having an attached end 357 and a colored, freeend 358. The surgeon may attach tissue marker 356 to tissue while it isin a compact configuration, using an applier as described for FIG. 3-5A.The surgeon then may grasp free end 358 with a conventional graspinginstrument to extend flag 359, thus making tissue marker 356 moreconspicuous.

FIG. 3-6 is a top view, FIG. 3-7 is a side view (before deployment), andFIG. 3-8 is a side sectional view (after deployment) of a second aspectof a tissue marker 305. Tissue marker 305 includes a disc 306 and areceiver 308. A pair of legs 307 extend from the bottom of disc 306, andinsert into a pair of ramps 309 in the bottom of receiver 308, so thatduring deployment, pair of legs 307 come together tip-to-tip to entraptissue. Receiver 308 retains disc 306 in a one-time assembly. Tissuemarker 305 attaches to tissue securely during the surgical procedure,but may be pulled off of the tissue when no longer needed. Tissue marker305 may be injection molded, for example, from any one of a number ofbiocompatible polymers.

FIG. 3-9 is a top view, FIG. 3-10 is a sectional side view (afterdeployment), and FIG. 3-11 is a side view (before deployment) of a thirdaspect of a tissue marker 310. Tissue marker 310 includes a plunger 311inserted into a housing 312. A hook 314 is attached to plunger 311 andextends from the bottom of housing 311 when the surgeon squeezes plunger311 and housing 312 together, much like the way a “fishing bobber” canbe attached to a fishing line. A spring 313 biases retraction of hook314 into housing 312. The surgeon may attach hook 314 into tissue andrelease plunger 311 to attach tissue marker 305 to the tissue. Plunger311 and receiver 312 may be made of a biocompatible polymer, and hook314 may be made of a stainless steel, for example.

FIG. 3-12 is a top view, FIG. 3-13 is a sectional side view (beforedeployment), and FIG. 3-14 is a side view (after deployment) of a fourthaspect of a tissue marker 315. Tissue marker 315 includes a plunger 316inserted into a housing 317. A spring hook 318 is attached to plunger316 and extends through the bottom of housing 317 and engages tissue(like a “cork screw”) when a surgeon grips plunger 316, and pushes androtates tissue marker 315 against the tissue of interest.

FIG. 3-15 is a side view, FIG. 3-16 is an end view, FIG. 3-17 is a frontview (before deployment), and FIG. 3-18 is a front view (afterdeployment) of a fifth aspect of a tissue marker 319. Tissue marker 319includes a crown 324 from which extend a pair of legs 321, spaced apartby a latch beam 323. A latch 322 extends from the bottom side of crown324, so that when the surgeon deploys tissue marker 319 into the tissueof interest, latch 322 engages with a hole in beam 323 to hold legs 321together, thus entrapping tissue and attaching tissue marker 319 to thetissue. A tab 320 extends from crown 320 to provide additionalvisibility and space for information. Tissue marker 319 may be injectionmolded from a biocompatible polymer. FIG. 3-19 is an end view, FIG. 3-20is a front view (before deployment), and FIG. 3-21 is a front view(after deployment) of a sixth aspect of a tissue marker 325. Tissuemarker 325 includes a hinged crown 326, from which extends a pair oflegs 327 separated by a spring beam 328. Tissue marker 325 employs an“over-center” method of holding legs 327 together after deployment. Whendeployed, the bending of spring beam 328 provides a locking force tohold hinge crown 326 in the deployed configuration as shown in FIG.3-21. Tissue marker 325 may be made of a biocompatible polymer.

FIG. 3-22 is a top view, FIG. 3-23 is a side view (before deployment),and FIG. 3-24 is a side view (after deployment) of a seventh aspect of atissue marker 329. Tissue marker 329 includes a clip 332 having a pairof legs 331 and molded from a biocompatible plastic. Clip 332 retains athin washer 330 in a first position (before deployment) and a secondposition (after deployment). Washer 330 may be formed from a metal, arigid polymer, or an absorbable material. Washer 330 holds legs 331together after deployment, thus entrapping tissue therebetween.

FIG. 3-25 is a top view, and FIG. 3-26 is a side view, of an eighthaspect of a tissue marker 333. Tissue marker 333 includes a button 334attached to one end of a flexible (but stiff) cord 335. An T-fastener336 is attached to the other end of cord 335. During deployment,T-fastener 336 is momentarily bent approximately parallel to cord 335and penetrated into tissue. When released, T-fastener 336 resumes theoriginal T-shaped configuration with cord 335, thus attaching tissuemarker 333 to the tissue. Tissue marker 333 may be made of abiocompatible polymer.

FIG. 3-27 is a top view, FIG. 3-28 is a sectional side view (beforedeployment), and FIG. 3-29 is a side view (after deployment) of a ninthaspect of a tissue marker 337. Tissue marker 337 includes a metal disc339 from which extends a pair of hooks 338 integrally formed from disc339 in a stamping process. Before deployment, hooks 338 extend from thetop side of disc 339. After deployment, hooks 338 extend from the bottomside of disc 339, thus entrapping tissue and attaching tissue marker 337to the tissue.

FIG. 3-30 is a top view, FIG. 3-31 is a side view before deployment, andFIG. 3-32 is a side view after deployment, of a tenth aspect of a tissuemarker 340. Tissue marker 340 includes a metallic clip 341, to which isattached a loop 342. A surgeon may attach tissue marker 340 to tissueusing any one of a number of conventional, surgical grasping andclamping instruments. FIG. 3-38 is an illustration of tissue marker 340being attached to tissue 399 using an endoscopic grasping instrument372. Loop 342 may be color coded to designate key anatomical landmarks,and also provides a convenient handle for manipulating tissue during theprocedure, or for attaching additional labels.

Surgeons have used marking pens routinely for marking incision lines onthe skin of patients, but before now, specialized instruments andmethods for marking lines on the surfaces of soft tissue inside the bodyhave not been available. In addition to using tissue markers to identifykey anatomical structures, the surgeon may also use marking fluids, forexample, to indicate internal cutting lines during the planning of asurgical procedure.

FIG. 3-33 is a side view of a first embodiment of a marking tissueapplier 343, which includes a syringe 348, a connector 347, a tube 346,a stylus 345, and a dispensing tip 344. The surgeon may insert stylus345 into the body cavity via a laparoscopic port. For hand-assistedsurgery, stylus 345 may be approximately 5-10 centimeters long andhandheld (like a pencil) by the surgeon inside the body cavity. Forlaparoscopic surgery, stylus 345 may be much longer (over 20centimeters) for access into the abdomen via a trocar cannula. Syringe348 may be filled with any one of a number of marking fluids, includinga biocompatible dye, stain, or colored adhesive. The surgeon may holdthe dispensing tip 344 near the tissue to be marked (see FIG. 3-39) andinject drops of marking fluid onto the tissue along the desired cuttingline.

FIG. 3-34 is a top view, and FIG. 3-35 is a side view of the distalportion of a second embodiment of a marking fluid applier 349. Markingfluid applier 349 includes a pair of opposable arms 351 extending fromthe distal end of a closing tube 350 and normally biased in an openconfiguration. An end effector 352 is attached to each of arms 351 andconfigured for grasping tissue (a closed configuration is shown withphantom lines) when closing tube 350 is moved distally by an actuator ona handle (not shown). FIG. 3-36 is an enlarged, side view of a tissueinterfacing surface 354 on one of end effectors 352. Surface 354contains a multiplicity of holes 353 for dispensing the marking fluidfrom a reservoir inside of end effector 352 (hidden) to the interfacingtissue. A tube 355 supplies marking fluid to end effector 352 from asyringe or other type of dispensing device on the proximal portion ofthe instrument (not shown). The diameter of holes 353 is dictatedprimarily by the viscosity of the marking fluid. Alternately, anabsorbent material such as a foam rubber may be used in combination orinstead of holes 353, so that marking fluid may be properly transferredfrom the reservoir to the tissue without excessive dripping, etc.

The surgeon may use the tissue markers and marking fluids described forFIG. 3-1 through FIG. 3-39 to help plan and execute a surgical procedureby identifying key, anatomical structures in the body cavity. A methodfor performing a sigmoidectomy (removal of the sigmoid colon) is brieflydescribed in conjunction with FIG. 3-37, and a method for performing aleft colonectomy (removal of the left colon) is briefly described inconjunction with FIG. 3-40 through FIG. 3-42. The broad method thatincludes the step of marking key anatomical structures, however, isequally applicable to numerous other surgical procedures, including anytype of colonectomy, nephrectomy, adrenalectomy, hepatic resection,distal gastrectomy, and exploratory surgery such as for trauma (knifeand gunshot wounds, etc.) and peritonitis.

FIG. 3-37 is an illustration of the colon 360 of a surgical patient. Adistal end point 366 is marked by tissue marker 301, and a proximal endpoint 368 is marked by another tissue marker 301 to identify the portion(with adequate margin of healthy tissue) of the diseased sigmoid colon362 to be resected. The mesenteric artery 370, which supplies arterialblood to the sigmoid colon 362, is marked by another tissue marker 301.A cutting line 364 is marked by a marking fluid 372. A method forresecting tissue from the body of a patient may include the followingsteps, although not necessarily in the order described. The surgeonaccesses the body cavity, such as through a laparoscopic port or disc.The surgeon identifies and attaches a first tissue marker to the distalend point of the tissue to be resected. The surgeon identifies andattaches a second tissue marker to the proximal end point of the tissueto be resected. The surgeon identifies a cutting line and marks thecutting line with a marking fluid. The surgeon identifies and attaches athird tissue marker to the vessel that supplies arterial blood to thetissue to be resected. The surgeon ligates the arterial blood supplywhere the third tissue marker is attached. The surgeon resects thetissue between the first and second tissue markers, and along thecutting line. The surgeon removes the tissue from the body cavity of thepatient.

FIG. 3-40 illustrates a portion of the colon 360 of a surgical patient,showing tissue marker 340 attached at a proximal end point 368, and acut line identified by marking fluid 372. (The distal end point 366 isnot visible.) A retraction device 374, attached to the body wall atfirst attachment 375 and second attachment 376, assist the surgeon invisualizing and accessing the surgical site. FIG. 3-41 illustrates thenext stage of the procedure, in which the mesenteric artery 370, hasbeen ligated with a surgical clip to block the blood supply to thetissue to be resected. Also, a portion of cutting line 364 has been cut(with a electrosurgical cutting instrument, for example) to create awindow in the mesentery for insertion of a stapling instrument. FIG.3-42 illustrates the next stage of the procedure, in which the surgeonhas stapled and cut across the colon 360 to isolate the proximal portionof the tissue to be resected from the surrounding healthy tissue. Thesurgeon may do a similar stapling and cutting of the distal portion ofthe colon 360.

Intra-Abdominal Storage Device

FIG. 4-1, FIG. 4-2, FIG. 4-3, and FIG. 4-4 are perspective views of afirst, a second, a third, and a fourth aspect, respectively, of anintra-abdominal storage device, also referred to as a storage device. Asurgeon may use the storage device for temporarily storing surgicalinstruments intra-abdominally (inside the abdominal cavity) duringhand-assisted laparoscopic (HAL) surgery. The surgeon may also use thestorage device to store and/or retrieve other objects associated withthe surgery, such as tissue specimens, sutures, and sponges, and inother types of surgery, including open or thoracic procedures. Duringthe HAL procedure and other minimally invasive procedures, the surgeonuses endoscopic visualization and has available a wide assortment ofendoscopic instruments to aid in the placement, use, and removal of thestorage device.

FIG. 4-1 is a perspective view of the first aspect of a storage device402A, which includes a pouch 404 having an opening 408 and a compartment403, a closing element 406, and an attaching element 410A. Pouch 404 maybe made of a thin, flexible, biocompatible material that is resistant totearing and puncture. For example, pouch 404 may be made of any one ofnumerous polymers including polyvinylchloride, polyethylene, polyester,polyurethane, and silicone films, and may alternately be made of a papermaterial, a mesh, or a fabric woven from a natural or synthetic fiber.Storage device 402A and its packaging, as provided to the surgeon, maybe sterilized using conventional methods such as gamma radiation, and ingeneral, is made of cost-effective, disposable materials.

The surgeon may removably attach storage device 402A to the inside ofthe body wall of the patient using attaching element 410A, so that thesurgeon may easily access storage device 402A during the surgicalprocedure to insert or remove surgical instruments. In this firstaspect, attaching element 410A may be made of a braided or monofilamentsuture material, or any one of a number of materials having appropriatetensile strength, including stainless steel wire, natural fibers, andpolymers.

In the first, second, third and fourth aspects of the storage device(402A, 402B, 402C, and 402D, respectively) closing element 406 is apurse string disposed around the perimeter of opening 408. Numerousother possible variations of closing element 406 include, but are notlimited to, a clip, wire twist, snap, button, spring wire device such asused for some coin purses, and an interlocking seal, such as “ZIPLOC”(trademark, S.C. Johnson and Co.) that is well known for the applicationof food storage bags.

Attaching element 410A is joined to a retaining element 412, whichprovides a flat and robust attachment to pouch 404 to secure storagedevice 402A to a structure in the body cavity. Retaining element 412 maybe secured to the inside of pouch 404 by any one of a number of methods,including adhering, sewing, or capturing in a fold of pouch 404.Retaining element 412 is a thin, flat, and relatively rigid, compared tothe material of pouch 404, and may be made, for example, of abiocompatible plastic or paper. Retaining element 412 may alternately besecured to the outside of pouch 404.

During the surgical procedure, the surgeon may introduce storage device402A into the body cavity of the patient via the main surgical openingthat provides access to the surgical site. The surgeon may fold or rollup storage device 402A to facilitate insertion into the body cavity,either via the primary surgical incision (that may contain a hand portor laparoscopic disc) or via a trocar cannula. As illustrated in FIG.4-9, attaching element 410A may be provided with a surgical needle 411attached to the free end so that the surgeon may pass the needle throughthe body wall from inside of body cavity 494 to outside of the body,thus minimizing the size of the wound and eliminating the step of firstmaking an body incision in body wall 494 for passing attaching element410A. Under laparoscopic visualization on the operating room monitor,the surgeon may insert and remove surgical instruments into opening 408.Alternately, the surgeon may pass the free end of attaching element 410A(without needle 411) through a small incision in the body wall, pullingattaching element 410A outwardly to position storage device 402A againstthe inside of the body wall. The surgeon may secure the free end ofattaching element 410A to the patient's skin using, for example, tape,suture, or staples. The surgeon may change storage device 402A from anopen configuration to a closed configuration by holding slip knot 407,while pulling on the free end of closing element 406. Conversely, thesurgeon may change storage device 402A from the closed to the openconfiguration by loosening closing element 406, in order to retrieve asurgical instrument. At the end of the surgical procedure, the surgeonmay easily detach the free end of attaching element 410A from thepatient, and remove storage device 402A from within the body cavity.Although not shown in the drawings, a suture needle may also be providedon the free end of closing element 406, so that the free end of closingelement 406 may be externalized, thus allowing the surgeon to closestorage device 402 from outside the body.

Storage device 402A and the other aspects of the storage device, may bemanufactured in a number of different sizes to accommodate varioussurgical procedures. For HAL procedures in which the surgeon may desireto temporarily store very small, fingertip instruments inside of thepatient's body, for example, the diameter of opening 408 may beapproximately in the range of 3-5 cm, and the length of pouch 404 may beapproximately in the range of 5-10 cm.

FIG. 4-2 is a perspective view of the second aspect of a storage device402B including pouch 404 having an opening 408. A partition 422separates a first compartment 418 from a second compartment 420. Thesurgeon may temporarily store a surgical instrument inside of each offirst compartment 418 and second compartment 420, keeping them separatedby partition 422, and thus allowing easy retrieval of one or the otherinstruments. The surgeon may use closing element 406, as described forthe first aspect, for closing and opening storage device 402B.

FIG. 4-3 is a perspective view of the third aspect of a storage device402C, including pouch 404 having opening 408. A partition 435 separatesa first compartment 424, a second compartment 426, and a thirdcompartment 428. The surgeon may separately store three surgicalinstruments in the third aspect of storage device 402C.

FIG. 4-4 is a perspective view of the fourth aspect of a storage device402D, including pouch 404 having an opening 408. A partition 446separates a first compartment 438, a second compartment 440, a thirdcompartment 442, and a fourth compartment 444. The surgeon mayseparately store four surgical instruments in the fourth aspect ofstorage device 402D.

Those skilled in the art will also recognize that storage devices 402B,402C, and 402D may be constructed using any one of numerous techniques.For example, separate plastic or cloth bags may be joined together toform a pouch with multiple compartments. Alternately, a single sheet ofpolymeric material may be folded and joined at seams by welding, gluing,or sewing, for example, to form a multi-compartment pouch. The pluralityof compartments may also be arranged in a row or in other arrangements.

FIG. 4-5, FIG. 4-6, FIG. 4-7, and FIG. 4-8 show embodiments of theattaching element, as adapted for the third aspect of storage device402C, although all embodiments are equally adaptable to the otheraspects of the storage device. Each embodiment allows the surgeon toremovably secure storage device 402C within a body cavity of a patientduring a surgical procedure.

FIG. 4-5 is a perspective view of storage device 402C, including asecond embodiment of attaching element 410B that includes an attachingrod 456 and a button 460. Attaching rod 456 may be made of abiocompatible plastic or metal and attached to retaining element 412, orattaching rod 456 and retaining element 412 may be injection molded fromplastic as one piece. Attaching rod 456 may also be made of a flexiblematerial, such as high density polyethylene, and passed through anincision already made in the body wall by the surgeon. Button 460 may bemade of a plastic such as polyethylene. The surgeon introduces storagedevice 402C into the body cavity of the patient, and pushes a piercingtip 459 of attaching rod 456 through the body wall, externalizingpiercing tip 459 and a portion of attaching rod 456. The surgeon holdsstorage device 402C firmly against the inside of the body wall and(perhaps with assistance) positions button 460 onto attaching rod 456 sothat a slot 462 of button 460 engages one of a plurality of teeth 458 onattaching rod 456, thus holding storage device 402C securely against theinside of the body wall. The surgeon may cover, bend over, or cut-offtip 459 to avoid accidental injury during the rest of the surgicalprocedure. The surgeon may remove button 460 from attachment rod 456 inorder to relocate storage device 402C or to remove storage device 402Cfrom the body cavity. The surgeon may also bend over the externalizedportion of attaching rod 456 and tape it to the skin of the patient,rather than use button 460.

FIG. 4-6 is a perspective view of a third embodiment of an attachingelement 410C, including an attaching rod 464 having a plurality of holes466, and a pin 468. Attaching rod 464 may be made of a rigid,biocompatible plastic or metal. Attaching rod 464 is attached to ormolded as one piece with retaining element 412. Attaching rod 464includes a piercing tip 469 so that attaching element 410 may bepositioned in the body wall as described for the first embodiment shownin FIG. 4-5. Once a portion of attaching rod 464 is externalized fromwithin the body cavity, the surgeon may insert a pin 468 into one of theplurality of holes 466 in attaching rod 464, to secure storage device402 inside of the body cavity. The piercing tip may be covered, bentover, or cut-off to prevent accidental injury during the procedure. Uponcompletion of the surgical procedure, the surgeon may easily remove pin468 and withdraw storage device 402C from the body cavity.

FIG. 4-7 is a perspective view of a fourth embodiment of an attachingelement 410D, including an elastic loop 470 attached to retainingelement 412. The surgeon may externalize a portion of elastic loop 470through a small incision in the body wall, and hold storage device 402against the inside of the body wall, for example, by pulling up onelastic loop 470 and clamping surgical clamps onto elastic loop 470against the skin of the patient. Alternately, elastic loop 470 may bestretched around the portion of the trocar cannula extending into thebody cavity, or around a portion of any one of a number of surgicalinstruments used during the surgical procedure and having at least aportion extending inside of the body cavity. Elastic loop 470 may bemade of a biocompatible elastomer, for example, such as silicone rubberor polyurethane rubber.

FIG. 4-8 is a perspective view of a fifth embodiment of an attachingelement 410E, including a clip 472 attached to retaining element 412with a fastener 474. The surgeon may removably attach clip 472 to theinternal portion of the cannula of a surgical trocar port as shown inFIG. 4-10. Fastener 474 may be a post that is molded integrally withretaining element 412, and loosely heat-staked to clip 472, so that clip472 may pivot. Clip 472 is made of a biocompatible, spring-like plasticor metal so that clip 472 may grip onto the trocar cannula. FIG. 4-11illustrates storage device 402C in the closed configuration and with thefifth embodiment of attaching element 410D (not shown in FIG. 4-11; seeFIG. 4-10) removably attached to the cannula 498 of a surgical trocar496 penetrating body wall 490. Closing element 406 has been drawnthrough slip knot 407 to securely contain a surgical instrument 499within storage device 402C.

FIG. 4-12 is a sectional view of a sixth embodiment of an attachingelement 410F, shown on storage device 402A in the open configuration andwithin the body of a patient. Sixth embodiment of attaching element 410Fincludes a tubular attaching rod 484 and a cap 486. Attaching rod 486has a flange 480, which is analogous to retaining element 412, and ismade of a biocompatible metal or plastic. The surgeon may initiallypenetrate attaching rod 484 into body wall 490 as described for theembodiments of the attaching element shown in FIG. 4-5 and FIG. 4-6. Thesixth embodiment shown in FIG. 4-12 includes the free ends of closingelement 406 (which is again a purse string disposed about opening 408))extending through a channel 477 of attaching rod 484 so that the surgeonmay close or open storage device 402C from outside of the patient. Thesurgeon may removably press cap 486 over attaching rod 484, as shown inFIG. 4-13, to hold storage device 402C in the closed configuration andto protect a piercing tip 479. A cap flange 482 presses against theoutside of body wall 490 to retain storage device 402C against theinside of body wall 494. Cap 486 is made of a biocompatible plastic orelastomer and has a tight sliding fit over attaching rod 484.

Other embodiments for the attaching element are possible. For example,attaching element may incorporate a ferrous material attached to thepouch and held against the inside of the body wall using an externalmagnet.

Surgical Retraction Device for Creating a Visceral Barrier

The viscera inside the abdominal cavity is highly mobile and slippery.During a hand-assisted laparoscopic procedure, for example, the surgeonmay need to “compartmentalize” the abdominal cavity in order to view andoperate on particular organs. During some laparoscopic procedures, thesurgeon tips the operating table to cause the patient's abdominalviscera to shift away from an area of interest in the body cavity. Thesurgeon may refrain from tipping certain patients (gun-shot woundedpatients, elderly patients, etc.) to minimize stress on the heart. Inthose and other cases, the surgeon may use any one of the numerousaspects of a retraction device illustrated in FIG. 5-1 through FIG. 5-52to “corral” viscera (such as the colon) out of the way, or to “put away”tissues already examined. The retraction device helps the surgeon tocreate a wall-like structure, or visceral barrier, at a transverseabdominal line somewhere between the rib cage and the pelvis. Theretraction device has a tissue interface with a large, projected areafor holding the viscera away from the surgical site. The surgeon may usethe retraction device to lift or to suspend tissue, such as whenexamining the vasculature the intestinal mesentery. The retractiondevice generally is easy to manipulate and position in the body cavity,easy to hold in position for the duration of the procedure, and easy toremove from the body cavity.

Turning now to the drawings, FIG. 5-1 illustrates a first aspect of asurgical retraction device 501 retracting a colon 500 of a surgicalpatient. Retraction device 501 includes an elongated column 502removeably attached to an attachment handle 504 centrally located on arectangular, barrier element 503. Column 502 includes a conventional,laparoscopic, surgical clamping instrument that the surgeon may passthrough a laparoscopic port (not shown) before attaching to attachmenthandle 504. The surgeon may introduce barrier element 503 into the bodycavity, for example, via the laparoscopic disc. Barrier element 503 isformed from a malleable material, such as a metallic wire reinforced,biocompatible elastomer. Barrier element 503 has a length ofapproximately 20 centimeters and a width of approximately 5 centimeters.The surgeon may use retraction device 501 in combination with a numberof ancillary, surgical instruments 599, to manipulate and supportvisceral tissues in the body cavity. Once the surgeon is satisfied withthe placement of the visceral barrier, the external portion of column502 may be held by a surgical assistant, weighted, or temporarilyattached to an immobile structure outside the body cavity.

The surgeon may use each of the remaining aspects of the retractingdevice in a similar fashion as the first aspect of FIG. 1, with somevariations as will be described. FIG. 5-2 is a perspective view of asecond aspect of a retraction device 505, which includes a bifurcatedcolumn 506 having a pair of arms 509. The end of each of arms 509pivotally attach to the opposing sides of a book-like, foldable barrierelement 507. A remotely operable, actuating rod 508 of column 506attaches to barrier element 507 so that the surgeon may changeretracting device 505 between a closed configuration and an openedconfiguration. The surgeon may introduce the distal portion ofretracting device 505 into the body cavity via a laparoscopic disc.

FIG. 5-3 is a perspective view of a third aspect of a retraction device510 including a column 511 removeably attached to a barrier element 512.Barrier element 512 has a plurality of vacuum apertures 513, whichfluidly communicate via a channel through column 511 with a vacuumsource (not shown). Barrier element 512 is covered with a cover material514, which may comprise a cotton gauze or fabric, to improve thesurgeon's ability to manipulate tissue atraumatically. The surgeon mayintroduce barrier element 512 through a laparoscopic disc or port beforeattaching it to the distal end of column 511.

FIG. 5-4 is a perspective view of a fourth aspect of a retraction device515, while in a closed configuration, and FIG. 5-4 shows retractiondevice 515 in an opened configuration. Retraction device 515 includesthree arms 517 extendable from the open, distal end of a column 516. Abarrier element 518, including a flexible material such as a fabric orplastic film, is attached to arms 517, so that when arms 517 areremotely actuated by the surgeon to extend from the end of column 516,arms 517 spread apart and tension barrier element 518.

FIG. 5-6 is a perspective view of a fifth aspect of a retraction device519, while in a closed configuration, and FIG. 5-7 shows retractiondevice 519 in an opened configuration. Retraction device 519 includes apair of parallel bars 521 that are extendable from the distal end of acolumn 520 so that bars 521 are perpendicular to column 520 in theopened configuration. Bars 521 are pivotally attached to column 520 sothat bars 521 are parallel to column 520 in the closed configuration,and so that the surgeon may pass the distal portion of retraction device519 through a laparoscopic port. A barrier element 523 is formed by awebbing material.

FIG. 5-8 is a perspective view of a sixth aspect of a retraction deviceincluding a pair of L-shaped, bar elements 526 that are covered with acover material 527, and each of which are attached at a common pivot 593to the distal end of a column 525. The surgeon may actuate bar elements526 to be approximately flush with the outside diameter of column 525while in a closed configuration, and to swing out to be perpendicular tocolumn 525 while in an opened configuration.

FIG. 5-9 is a perspective view of an seventh aspect of a retractiondevice 528 including a barrier element 530 that is extendable from theopen end of a column 529. Barrier element 530 may be formed from a flatstock of spring steel that forms a ninety degree bend whenunconstrained. Barrier element 530 is covered with a cover material 531.

FIG. 5-10 illustrates an eighth aspect of a retraction device 532, whilein an opened configuration and retracting the colon 500 of a surgicalpatient. Retraction device 532 includes a pair of arms 534 attached toan attachment handle 535, which a surgeon may hold with a conventionallaparoscopic clamp 533. Arms 534 may be opened as shown to form aV-shape, tensioning a pair of cords 537 attached to arms 534. A webbingtype, barrier element 536 is attached to cords 537 and arms 534, forminga large, see-through, tissue interface surface while in an openedconfiguration.

FIG. 5-11 illustrates a ninth aspect of a retraction device 538, whilein an opened configuration and retracting the colon 500 of a surgicalpatient. Retraction device 538 includes a webbing type, barrier element542 attached to a collapsible, elliptical ring 594, which may be made ofa spring steel wire or a shape-memory metal (Nitinol). The ends of abeam element 541 are attached to ring 594. A handle 542 centrallylocated on beam element 541 provides a convenient grasping point for alaparoscopic clamping instrument 539.

FIG. 5-12 is a perspective view a tenth aspect of a retraction device543 in a closed configuration. FIG.-13A shows retraction device 543while in a partially open configuration. FIG. 5-13B shows retractiondevice 543 while in an opened configuration. Retraction device 543includes a barrier element 545 that passes through a hollow column 544.Barrier element 545 is formed by a band composed of a flexible but stiffmaterial such as high density polyethylene. The distal end of barrierelement 545 extends out of the open, distal end of column 544, and isattached to an attachment canopy 547 on the outside of column 544. Asshown in the drawings, the surgeon may remotely push barrier element 545out of the open end of column 544 to form a T-shape, supported in thecenter of the extended barrier element 545 by a remotely operable rod546.

FIG. 5-14 is a perspective view of an eleventh aspect of a retractiondevice 548 including a pair of arms 550 that may be retracted into theopen end of a column 549 by a retraction rod 595.

FIG. 5-15 is a perspective view of a twelfth aspect of a retractiondevice 551, shown retracting the colon 500. Retraction device 551includes a pair of arms 553 formed from a flat, spring material andextendable from a column 552.

FIG. 5-16 is a side view of a thirteenth aspect of a retraction device554 while in an opened configuration. FIG. 5-17 shows a partially openedconfiguration, and FIG. 5-18 shows a closed configuration. Retractiondevice 554 includes a barrier element 558 formed by a collapsible frame556 and a webbing 557. Barrier element 558 is retractable into the openend of a column 555, to facilitate introduction into and removal fromthe body cavity via a laparoscopic port.

FIG. 5-19 illustrates a fourteenth aspect of a retraction device 559retracting the colon 500 of a surgical patient. Retraction device 559includes a pair of arms 561 that spring apart when not constrainedinside the open end of a column 560. On the end of each arm is a pad 562having an atraumatic cover 563 (see FIG. 5-20).

Each of the following aspects of the retraction device (shown in FIG.5-21 through FIG. 5-52) comprise a wall-like, barrier element thatoptionally may be positioned and held in the body cavity by alaparoscopic clamping instrument. For clarity, the clamping instrumentis not shown in some of FIG. 5-21 through FIG. 5-52. Each of thefollowing aspects of the retraction device may be “self-supporting”inside of the body cavity. That is, the perimeter of the barrier elementis positionable against the body wall and organs within the body cavityto remain in place without being held by a clamping instrument. In mostaspects to be described, however, handles are provided on the barrierelements to facilitate manipulation and holding by a clampinginstrument. Each of the aspects of the retracting device shown in FIG.5-21 through FIG. 5-52 may be sized, while in the opened configuration,to substantially span either or both the transverse width and thevertical height of the patient's body cavity.

FIG. 5-21 is a sectional view of a fifteenth aspect of a retractiondevice 564, while in a closed configuration and being passed through alaparoscopic port. FIG. 5-22 is an end view of retraction device 564,while in the extended configuration. FIG. 5-23 is a front view ofretraction device 564, while in the closed configuration. Retractiondevice 564 includes a plurality of panel barrier elements 565 attachedtogether, edge-to-edge, in a row by a plurality of hinges 567.Retraction device 564 includes a plurality of handle cutouts 566 tofacilitate grasping by a clamping instrument. In one version of thisaspect, each of hinges 567 may flex in either direction so that panels565 may be rolled up from either side. In another version of thisaspect, hinges 567 may flex in only one direction so that panels 565 maybe rolled up from only one side. When unrolled to the openedconfiguration, retraction device 564 resists bending from one direction.

FIG. 5-24 is a front view of a sixteenth aspect of a retraction device568 including a first barrier element 569 and a second barrier element570 that interlock at a central, interlocking joint 571 once introducedinto the body cavity. A cover material 572, such as a gauze of fabric,covers each of first and second barrier elements, 569 and 570. Thesurgeon may hold retraction device 568 with a clamping instrumentclamped onto one of handles 573.

FIG. 5-25 illustrates an seventeenth aspect of a retraction device 574retracting the colon 500 of a surgical patient. FIG. 5-26A is a frontview of retraction device 574, while in an opened configuration. FIG.5-26B is a front view of retraction device 574, while in a partiallyclosed configuration. Retraction device 547 includes four panel barrierelements joined together at folds 577, and includes a plurality ofhandle cutouts 576. Retraction device 547 may be die-cut from apolyethylene sheet, for example, with folds 577 includingthermally-formed creases. As shown in FIG. 5-26B, retraction device 574is foldable in a concertina manner, and may be easily deployed into theopened configuration while inside the body cavity.

FIG. 5-27 illustrates an eighteenth aspect of a retraction device 578retracting the colon 500 of a surgical patient. Retraction device 578includes a barrier element 579 formed by a plurality of frames 581flexibly joined in a row, side-to-side. Each of frames 581 is coveredwith a mesh or webbing material.

FIG. 5-28 illustrates a nineteenth aspect of a retraction device 582retracting the colon 500 of a surgical patient. Retraction device 582includes a barrier element 583 formed from a sheet of flexible,biocompatible material, such as polyethylene, and including a pluralityof handle cut-outs 584.

FIG. 5-29 is a perspective view of a twentieth aspect of a retractiondevice 585 including a barrier element 586 injection molded from abiocompatible polymer such as polypropylene. Retraction device 585includes a plurality of handle projections 587 extending from one sideof barrier element 586, and a plurality of handle cutouts 588.

FIG. 5-30 is a front view of a twenty-first aspect of a retractiondevice 589, while in a first, partially closed configuration. FIG. 5-31shows retraction device 589, while in a second, partially closedconfiguration. FIG. 5-32 shows retraction device 589, while in an openedconfiguration. Retraction device 589 includes four panel barrierelements joined by a plurality of hinges 591, and including a pluralityof handle cutouts 592. Retraction device 589 may be formed, for example,by either a die-cutting or an injection molding process from abiocompatible polymer.

FIG. 5-33 is a top view and FIG. 5-34 is a front view of a twenty-secondaspect of a retraction device 5000, which includes four panel barrierelements 5001 joined edge-to-edge in a row by three pinned hinges 5002that swing in either direction. Panels 5001 may be formed from a metalor injection molded from a biocompatible polymer. Each of hinges 5002may contain a detent or locking feature that holds panels 5001 in theinstant configuration until a sufficient external force is applied.Retraction device 5000 includes a plurality of handle cutouts 5003.

FIG. 5-35 is a top view and FIG. 5-36 is a front view of a twenty-thirdaspect of a retraction device 5005. Retraction device 5005 includes fourpanel barrier elements 5006 joined together in a row by a plurality offlexible bands 5007 woven alternately on the front and the back sides ofeach of barrier elements 5006, forming three hinges 5008 that may swingin either direction. A surgeon may extend and position retraction device5005 in the body cavity and allow the abdominal wall to rest on the topedge of retraction device 5005, perhaps by reducing insufflationpressure in the body cavity, so that retraction device 5005 may remainextended while resisting the force of tissue bearing against it.

FIG. 5-37A is a top view and FIG. 5-38 is a front view of atwenty-fourth aspect of a retraction device 5010, while in an extendedconfiguration. FIG. 5-37B is a detailed, top view of retraction device5010, while being folded into a rolled-up or closed configuration.Retraction device 5010 includes a plurality of panel barrier elements5011 joined together edge-to-edge in a row by a plurality of hinges5013. A plurality of wires 5012 embedded in barrier elements 5011 formhinges 5013. A plurality of stop elements 5009 attached to or integrallyformed on the tissue-bearing side of each of panel barrier elements 5011are arranged so that retraction device 5010 may fold in only onedirection. This allows the surgeon to introduce retraction device 5010while in the rolled-up or closed configuration into the body cavity.When in the extended configuration, retraction device 5010 resists theforce of tissue bearing against it, so that it remains extended.

FIG. 5-39 is a top view, FIG. 5-40 is a front view, and FIG. 5-41 is anend view of a twenty-fifth aspect of a retraction device 5015.Retraction device 5015 includes a malleable barrier element 5016 formedfrom a metallic mesh 5018 embedded in a biocompatible, elastomericmaterial 5019. Metallic mesh 5018 may be formed from a screen-likematerial, a plurality of wires or rods, and the like. Barrier element5016 includes a plurality of fingers 5017 that may be bent over to adesired shape to fit inside the body cavity and properly retract tissue.The surgeon may easily form barrier element 5016 into the desired shapeafter placement into the body cavity, but barrier element 5019 is stiffenough to provide a visceral barrier.

FIG. 5-42 is a front view of a twenty-sixth aspect of a retractiondevice 5021. FIG. 5-43 shows retraction device 5021, while in a twistedconfiguration. Retraction device 5021 includes a barrier element 5024formed from a metallic mesh 5022 covered with an polymeric,biocompatible coating. The surgeon may easily form barrier element 5024into the desired shape after placement into the body cavity, but barrierelement 5024 is stiff enough to provide a visceral barrier.

FIG. 5-44 is a top view and FIG. 5-45 is a front view of atwenty-seventh aspect of a retraction device 5027, including a pluralityof panel barrier elements 5028 joined together edge-to-edge in a row bya pair of flexible bands 5030. Because barrier elements 5028 areassembled with substantially no gap between adjoining barrier elements,and because bands 5030 are affixed to only one side of barrier elements5028, retraction device 5027 may flex in only one direction. The surgeonmay position retraction device 5027 against the viscera so thatretraction device 5027 is flexible in the distal direction (towards theviscera) to create the visceral barrier. A flexible, plastic cover 5029is provided to cover potential pinch-points between adjoining barrierelements 5028.

FIG. 5-46 is a top view and FIG. 5-47 is a front view of a twenty-eighthaspect of a retraction device 5031, including a barrier element 5032formed by a plurality of nested segments 5033 that may telescope in onedirection between an opened and a closed configuration. A secondretraction device 5031 may be joined by numerous methods (barb and hooklatches, for example) to a first so that the two nested segments 5033 ofthe two retraction devices 5031 telescope in opposing, lateraldirections. Sliding-fit frictional force, detents, or interlockingfeatures may be incorporated into nested segments 5033 to holdretraction device 5031 in the desired configuration to provide aneffective visceral barrier, yet be adjustable by the surgeon within thebody cavity.

FIG. 5-48 is a top view and FIG. 5-49 is a front view of a twenty-ninthaspect of a retraction device 5035, including a plurality of panelbarrier elements 5036 joined together, edge to edge in a row, by aplurality of hinges 5037. Barrier elements 5036 may be unitarily formed,such as by die-cutting from a sheet of polyethylene. Hinges 5037 may bethermally formed creases in the sheet material. A plurality ofextendable fingers 5039, which may be made from the same material asbarrier elements 5036, are pivotally attached to barrier elements 5036.The surgeon may swing each of fingers 5039 independently between a downand an up position as required, to increase the effective height of thevisceral barrier. Retraction device 5035 also includes a plurality ofwindows 5038 for viewing through the device or for grasping with aclamping instrument.

FIG. 5-50 is a top view of a thirtieth aspect of a retraction device5042. FIG. 5-51 is a front view of retraction device 5042, while in aclosed configuration. FIG. 5-52 is a front view of retraction device5042, while in an opened configuration. Retraction device 5042 includesa hollow, barrier element 5043 that houses a curtain 5047 in the closedconfiguration. The ends of a flexible dowel 5045 are inserted into theopposing ends of barrier element 5043. An external loop portion 5040 ofdowel 5045 wraps around approximately one half of the perimeter ofbarrier element 5043. The ends of dowel 5045 are operably connected toan extension mechanism 5046 inside of barrier element 5043. The top ofcurtain 5047 is attached to loop portion 5040, and the bottom of curtain5047 is retained inside of barrier element 5043. The surgeon may grasp ahandle 5044 with a clamping instrument and rotate handle 5044 in thecounter clockwise direction to deploy curtain 5047 to extend the heightof barrier element 5043. Curtain 5047 may be formed from any one of anumber of fabrics, mesh materials, films, and the like.

FIG. 5-53, FIG. 5-54, and FIG. 5-55 show a thirty-first aspect of aretraction device 5050 including at least one central panel 5052 ofuniform thickness, and a pair of end panels, 5054 and 5056, eachattached to central panel 5052 by at least one flexible hinge element5058, and each having a non-uniform thickness that tapers in a directionaway from hinge element 5058. As shown in FIG. 5-55, end panels 5054 and5056 may fold onto central panel 5052 so that the overall thickness ofretraction device 5050 is relatively small as compared to a similardevice in which all panels have a uniform thickness.

FIG. 5-56 is a front view and FIG. 5-57 is an end view of athirty-second aspect of a retraction device 5060 while in an extendedconfiguration. Retraction device 5060 includes a plurality of panels5062 joined by a plurality of hinges 5064. Each of panels 5062 may beformed from a spring-like material, such as for example, shape memorymetal (Nitinol) so that each panel 5062 may be flattened for rolling upinto a closed configuration for introduction into the body cavity. Whenretraction device 5060 is in the extended configuration, each of panels5062 may curl as shown in FIG. 5-57 so that retraction device 5060 mayresist the force of tissue bearing against one side and form aneffective partition.

Surgical Instrument System Having Removably Attachable End Effectors

During some surgical procedures, the surgeon must grasp, clamp, retract,suspend, and/or manipulate soft, fluidic tissues within the insufflatedbody cavity, being careful not to injure the tissues. In open surgicalprocedures, the surgeon has a large array of surgical instruments withlarge end effectors specifically designed for various steps of theprocedure. Also in open surgical procedures, the surgeon often places afolded-over, gauze sponge within the end effectors of an open surgeryinstrument to broaden and soften the tissue interface surface. Duringtraditional, laparoscopic procedures, it is not always possible to passsuch large instruments or a folded sponge through a laparoscopic port.During hand-assisted, laparoscopic procedures, however, the lap discprovides a relatively large port for introducing devices into the bodycavity, with only momentary loss of insufflation pressure. Consequently,it is possible to provide a surgical system that allows a surgeon tointroduce a surgical instrument with extra large end effectors into abody cavity.

FIG. 6-1 through FIG. 6-11 show numerous aspects of surgicalinstruments, each having removably attachable end effectors that are toolarge to pass through a conventionally sized trocar cannula. FIG. 6-1 isa front view of the distal portion of a first embodiment of a surgicalinstrument 601, shown with a first end effector 614 and a second endeffector 616. A first arm 604 and an opposable second arm 606 extendfrom the distal end of an elongated shaft 602, which may pass through aconventional trocar cannula when end effectors 614 and 616 are notattached. Surgical instrument 601 includes a handle with an actuator(not shown) for opening and closing arms 604 and 606. As shown for arm604 in FIG. 6-2 and FIG. 6-3, each of arms 604 and 606 has an attachmentslot 608 and a detent recess 610. Each of first and second end effectors614 and 616 also has an attachment element 620 for insertion intoattachment slot 608, and a detent 612 for engagement with detent recess610. Each of first and second end effectors 614 and 616 has anatraumatic grasping element 618 made of a soft, elastic, biocompatiblematerial such as a foam rubber. When end effectors 614 and 616 areattached to arms 604 and 606, the distal portion of surgical instrument601 may be too large to pass through some conventional, laparoscopicports.

Atraumatic grasping elements 618 may also be formed or coated from anyone of a number of medical grade hydrophilic polymers. These polymershave high water permeability, are waterproof, have low water absorption,have high flexibility and impact strength at low temperatures, have goodmechanical and elastic properties, have good heat stability, have goodresistance to chemicals, and are easy to process. Very common commercialhydrophilic materials are copolymers made of polyethylene oxide,crystallizable polyamide, polyurethane, and polyester.

FIG. 6-4 is a front sectional view of a second embodiment of an arm 626having an attachment aperture 626 and a female thread 628. An alternateversion of an end effector 621 has an attachment element 622 with a malethread 624 for removable attachment to arm 630. Attachment elements 620and 622 are only examples of the many types of features for removablyattaching an end effector to an arm of a surgical instrument, as isapparent to those skilled in the art.

FIG. 6-5 is an end view and FIG. 6-6 is a front view of a second aspectof an end effector 632, including a pair of parallel side walls 634 and636 connected by three, transverse columns 638 arranged to hold areplenishable, tissue interface element 640. Interface element 640 maybe formed, for example, from a conventional, surgical sponge or gauzematerial. End effector 632 also includes attachment element 620 anddetent 612, as shown for end effector 614 in FIG. 6-1, for removableattachment to surgical instrument 601.

FIG. 6-7 is an end view and FIG. 608 is a front view of a third aspectof an end effector, which is the same as end effector 632 shown in FIG.6-6, but having a replenishable, tissue interface element 644 formedfrom a roll of biocompatible material such as cotton gauze or a siliconefoam tape, for example. Interface element 644 includes a free end 646that may be pulled by the surgeon to present a fresh surface ofinterface element 644 to the tissue. Free end 646 may be externalizedthrough the body wall via the laparoscopic port so that the surgeon mayremotely replenish interface element 644.

FIG. 6-9 is a front view and FIG. 6-10 is a top view of the distalportion of a surgical instrument 646, shown with a first end effector650 and a second end effector 652, each of which represent a fourthaspect of an end effector. Surgical instrument 646 includes a pair ofopposing, wire-formed arms 654 and 656. The surgeon remotely operatesclosing tube 648 to translate longitudinally in the distal direction toclose arms 654 and 656, and in the proximal direction to open arms 654and 656. Each of first and second end effectors 650 and 652 has a slot658 (see FIG. 6-11) for removable attachment onto arms 654 and 656. Endeffectors 650 and 652 may be formed by any one or a composite of anumber of biocompatible materials, including a foam rubber or a lowdurometer silicone rubber. Slot 658 may be sized to stretch slightlyduring attachment to one of arms 654 and 656 to insure retention duringuse.

FIG. 6-12 illustrates part of a first method for performing ahand-assisted, laparoscopic procedure. The method includes providing asurgical instrument system 670 that includes a lap disc 662 and asurgical instrument 601 with a first and a second, detachable endeffector, 614 and 616. The method further includes placing lap disc 662in the body wall 666 of the patient, placing the distal portion ofsurgical instrument 601 into body cavity 668 when end effectors 614, 616are not attached to surgical instrument 601, introducing end effectors614, 616 into body cavity 668 via lap disc 662, and assembling endeffectors 614, 616 to surgical instrument 601. For removal of surgicalinstrument 601, the method further includes removing end effectors 614,616 from the surgical instrument 601, removing surgical instrument 601from body wall 666, and removing end effectors 614, 615 from body cavity668 via lap disc 662. The first method may also include the step ofstoring the end effectors in an intra-abdominal storage device (see FIG.4-1 through 4-15) inside of the body cavity.

FIG. 6-13 illustrates part of a second method of performing ahand-assisted, laparoscopic procedure. The second method includesproviding a surgical instrument system 672 that includes a lap disc 662,a lap disc insert 680 having at least one port 682, and a surgicalinstrument 601 with a first and a second, detachable end effector, 614and 616. The method further includes placing lap disc 662 in the bodywall 666 of the patient, placing the distal portion of surgicalinstrument 601 through lap disc port 682 of lap disc insert 680,attaching end effectors 614, 616 to surgical instrument 601, andattaching lap disc insert 680 to lap disc 662 so that end effectors 614,616 are inside body cavity 668. For removal of surgical instrument 601from body cavity 668, the method further includes removing lap discinsert 680 from lap disc 662 so that end effectors 614, 616 are removedfrom body cavity 668 via lap disc 662.

The first and second methods for performing a hand-assisted,laparoscopic procedure may also be used with other surgical instrumentshaving removably attachable end effectors. The first and second methodsmay also include insufflating the body cavity while the end effectorsare inside the body cavity.

Tissue Suspension Device

FIG. 7-1 through FIG. 7-13 disclose a tissue suspension device forsuspending tissues within the body cavity of a patient. A surgeon mayuse the tissue suspension device in combination with insufflation,orientation of the patient, and other well-known laparoscopic surgerytechniques, to improve visualization of and access to tissues ofinterest within the abdominal cavity during a hand-assisted,laparoscopic procedure. The surgeon may also use the tissue suspensiondevice for open, abdominal, surgical procedures, to eliminate the needfor other retraction devices currently used that partially obstruct thesurgical opening, to provide the surgeon with improved access andvisualization into the abdominal cavity.

FIG. 7-1 is a side view of surgical patient 799 while abdomen 798 isinsufflated with carbon dioxide. For clarity, the associatedinstruments, systems, and personnel required for laparoscopic surgeryare not shown. FIG. 7-2 is a cross-sectional view of patient 799, takenat line 2-2 of FIG. 7-1. A first aspect of a tissue suspension device702 suspends an organ 796 (in this example, the transverse colon).Tissue suspension device 702 includes an elongated spanning element 704having a first end 712 removably attached to body wall 794 by a firstsupporting element 708, and a second end 714 removably attached to bodywall 794 with a second supporting element 709. The patient's body wall,therefore, supports the weight of the suspended tissue, as opposed to“wall lift” or “gasless surgery” devices that attach to a structuremounted on the surgical table and are sometimes used in place ofinsufflation to enlarge the body cavity. Suspension system 702 furtherincludes at least one, hook-like suspending element 706 removablyattached to spanning element 704. FIG. 7-1 shows a pair of suspendingelements 706 suspending organ 796 within body cavity 792, therebyproviding improved access to and visualization of the mesentericvasculature 790, which supplies blood to organ 796.

FIG. 7-3 through FIG. 7-6 show additional views of suspension system702. FIG. 7-4 shows spanning element 704 with a plurality of holes 716arranged to provide multiple positions for inserting a pair of ends 707of suspending element 706. Each of first end 712 and second end 714 ofspanning element 704 includes an offset 728. Offset 728 allows thesurgeon to attach spanning element 704 to the body wall whilemaintaining an assured vertical clearance between the top of the bodycavity and spanning element 704. FIG. 7-6A shows first end 712 having aretention portion 726 for the removable attachment of a firstelastomeric tube 710 of supporting element 708. FIG. 7-5 shows secondend 714 having a retention portion 726 for the removable attachment of asecond, elastomeric tube 710 of supporting element 709. In a manner tobe described, the surgeon places spanning element 704 across the bodycavity so that first end 712 extends through the body wall on one sideof the patient and second end 714 extends through the body wall on theopposite side of the patient. Then the surgeon may attach one of tubes710 on each of first and second ends, 712 and 714. The surgeon next mayplace one of a pair of cuffs 711 onto each of first and second ends, 712and 714, to atraumatically support spanning element 704 against theexternal surface of body wall 794. Each cuff 711 has a pair of parallelslits 713 for “weaving” onto first and second ends, 712 and 714. FIG.7-6B shows first end 712 assembled to supporting element 708. Cuffs 711also provide torsional resistance to spanning element 704, which maytend to twist within the body wall when supporting tissue.

The surgeon may position spanning element 704 into the body cavity usinga number of methods. For example, the surgeon may first incise body wall794 with a scalpel, or penetrate the body wall with a sharp tip 722 ofsecond end 714, and then guide second end 714 across the body cavity toavoid accidental injury to internal organs, using his/her hand insertedinto the body cavity via the laparoscopic disc. The surgeon may thenpenetrate the body wall on the opposite side of the patient, or createan incision with a scalpel, to externalize second end 714. In anotherexample, the surgeon may attach a cap 718 (FIG. 7-5) onto retentionportion 724 of second end 714. The surgeon may then insert the free endof a filament 720, which may be a metal wire or a suture attached to cap718, into an entry incision on one side of the patient, and out of anexit incision on the other side of the patient. Then the surgeon may usefilament 720 to pull spanning element 704 into the body cavity.Alternately, a needle (not shown) may be attached to the free end offilament 720 for penetration through the body wall.

Once the surgeon has placed spanning element 704 into the body cavityand attached first and second ends, 712 and 714, to the body wall, thesurgeon may next hook at least one suspending element into a pair ofadjacent holes 716 of spanning element 704, again using his/her handinserted into the body cavity via the laparoscopic disc. The surgeon maythen lift the tissue/organ into suspending element 706. When the surgeonno longer needs suspension system 702, the surgeon may remove suspendingelement 706, detach either first end 712 or second end 714 from one sideof the patient, and pull spanning element 704 out of the opposite sideof the patient. Alternately, the surgeon may merely hook suspendingelement 706 over spanning element 704, rather than using holes 716.Although not shown in the figures, it is possible also to providespaced-apart, annular grooves along the length of spanning element 704.The surgeon may hook suspending element 706 into the grooves so thatsuspending element 706 may not slide along the length of spanningelement 704, but is permitted to rotate about the axis of spanningelement 704.

Each of supporting element 706, spanning element 704, tube 710, and cap718 may be formed from any one of a number of rigid, biocompatiblematerials, including a metal such as stainless steel. Supporting element706 may also be formed from a semi-rigid material, such as a malleablemetal coated with an elastomer or hydrophilic material, so that thesurgeon can reshape supporting element 706 during the surgicalprocedure. Supporting element 706 may also be formed from a memory metal(Nitinol) so that it may be folded to facilitate placement into (perhapsthrough a trocar cannula) or removal out of the body cavity.

FIG. 7-7 through FIG. 7-10 show views of a second aspect of a tissuesuspension device 732, including a spanning element 740, a pair ofsupporting elements 736, and at least one, hook-like suspending element738. Spanning element 740 is a straight bar having a plurality of holes740 spaced apart along its length. Each hole is sized and oriented toreceive an end 737 of supporting element 736. Suspending element 738includes a tray 739 onto which the surgeon may hang a tissue/organ. FIG.7-9 is an enlarged view of supporting element 736, which includes a cord741 attached to spanning element 734, and a plurality of spaced-apart,bead-like markers 742 attached to cord 741. Supporting element 736further includes a retaining element 744 having a slot 746 for receivingcord 741 (see FIG. 7-10). Once the surgeon has placed spanning element734 into the body cavity via the laparoscopic disc or a small incisionin the body wall, the surgeon may externalized each cord 741 through anappropriately placed incision in the body wall, and lift up on cord 741to raise spanning element 734. Alternately, a needle (not shown) may beattached to the free end of each of cords 741, so that the surgeon maypenetrate the needle through the body wall from inside the body cavity.The surgeon may use markers 742 to estimate the position of spanningelement 734 in the body cavity, and then position retaining element 744onto cord 741 to hold spanning element 734 at the desired verticalheight inside of the body cavity. Spanning element 734 is therebysuspended from the body wall like a trapeze so that the suspendedtissue/organ has additional mobility. To remove suspension system 732,the surgeon uses the reverse of the preceding procedure.

Spanning element 734 and suspending element 738 may be formed from anyone of a number of rigid, biocompatible materials, including stainlesssteel. Supporting element 736 and retaining element 744 may be formed,for example, from a polymer. Spanning element 734 may be coated with ananti-bacterial agent and/or a lubricious coating to facilitate insertionthrough the body wall. At least a portion of supporting element 738 maybe coated or covered with a soft material, such as a medical gradehydrophilic material, a foam rubber, or a cotton gauze, to provide anatraumatic support for the tissue/organ. Tray 738 may be formed from amalleable material, such as an annealed stainless steel, so that thesurgeon may reshape it while it is inside of the body cavity. Tray 738may be curved to help retain the slippery tissue within it, and thedepth of the curvature may be approximately in the range of, but notlimited to, 2-6 centimeters.

FIG. 7-11 shows a partial view of a third aspect of a tissue suspensiondevice 748, including a hollow, spanning element 750 formed from a rigidmaterial such as stainless steel tubing. Spanning element 750 includes aplurality of spaced-apart holes 752 for the removable attachment ofsuspending element 738 shown in FIG. 7-8. The surgeon places spanningelement 750 into the patient using a guide wire 754. The surgeon createsa first incision in the body wall on one side of the patient and insertsan end of guide wire 754. The surgeon then pulls guide wire 754 acrossthe body cavity, using his/her hand inserted into the body cavity viathe laparoscopic disc. The surgeon then passes the end of guide wire 754out a second incision in the body wall on the opposite side of thepatient. The surgeon next threads the external portion of guide wire 754through spanning element 750, and pushes spanning element 750 into thefirst incision along guide wire 754, across the body cavity, and out thesecond incision. The surgeon may then remove guide wire 754 fromspanning element 750, and secure the externalized ends of spanningelement 750 to the skin of the patient using a medical adhesive tape,for example.

FIG. 7-12 shows a fourth aspect of a tissue suspension device 758,including an articulating spanning element 759 made from a titaniumalloy or a stainless steel bar or tube, for example, and having aplurality of holes 760 for the removable attachment of suspendingelement 738 shown in FIG. 7-8. The surgeon may use supporting element708 shown in FIG. 7-6A to removably attach spanning element 759 to thebody wall. At least one end of spanning element 759 has an articulatingelement 762 that may swing about a pivot 764. The surgeon may adjustarticulating element 762 to a shortened configuration while introducingspanning element 759 into the body cavity via the laparoscopic disc. Thesurgeon may then use a scalpel to create two incisions in the body wallto externalize the ends of articulating element 762 at the locationsbest suited for supporting spanning element 759.

FIG. 7-13 shows a fifth aspect of a tissue suspension device 768,including a flexible spanning element 770 and a pair of adjustabletension, supporting elements 771. Each of supporting elements 771include a threaded rod 772 attached with a connector to flexiblespanning element 770, and a tensioning knob 774. While knobs 774 aredetached from threaded rods 772, the surgeon may position spanningelement 770 into the patient using any of the methods described for theprevious aspects, so that each of threaded rods 772 extends through thebody wall. The surgeon may then screw one tensioning knob 774 on each ofthreaded rods 772, and tension spanning element 770 by rotating one orboth of the tensioning knobs in the appropriate direction. The surgeonmay then hook at least one suspending element such as shown in FIG. 7-4onto spanning element 770. Spanning element 770 may be formed from, butis not limited to, any one or a combination of the following materials:a plastic cord or bar, a braided metal wire, a natural or a syntheticfiber rope, an extruded rubber or plastic tube, a malleable metal bar, awire-reinforced elastomer, a hydrophilic material, and a “gooseneck”conduit such as used for certain desk lamps.

While the present invention has been illustrated by description ofseveral embodiments, it is not the intention of the applicant torestrict or limit the spirit and scope of the appended claims to suchdetail. Numerous variations, changes, and substitutions will occur tothose skilled in the art without departing from the scope of theinvention. Moreover, the structure of each element associated with thepresent invention can be alternatively described as a means forproviding the function performed by the element. Accordingly, it isintended that the invention be limited only by the spirit and scope ofthe appended claims.

What is claimed is:
 1. A surgical port assembly comprising: a rigidmounting ring disposable on and releasably attachable a patient's skinsurface; a body member attachable to said ring to depend downwardlytherefrom through an incision in the patient's skin surface tofacilitate deployment of instruments in the patient via the incision,said body member having an outer side facing away from the patient andan inner side facing inwardly of or towards the patient's skin surfaceduring a surgical procedure, said body member being rotatably attachableto said ring for turning about an axis oriented perpendicularly to aplane defined by said ring; and a cannula unit attachable to said bodymember and carrying a plurality of cannulas.